R. Renard-Penna

Current practice and access to prostate MR imaging in France

PURPOSEnTo obtain an overview of the degree of discrepancy between current clinical practice of prostate magnetic resonance imaging (MRI) in France and recommendations.nnnMATERIALS AND METHODSnA brief survey was sent to 1229xa0members of the French society of urology in order to identify their indications of prostate MRI and its impact on patient management. The urologists were asked to answer several questions regarding age, practice modality, prostate MRI examinations (technique, indication before first biopsy, second biopsy, cancer staging, active surveillance, recurrence, focal therapy) and quality of reports.nnnRESULTSnA total of 445xa0responses were received (participation rate of 36%). The mean delay for obtaining an appointment for prostate MRI ranged between 15-30xa0days in 54%. Fifty-four percent of MRI reports contained a PIRADS score and 23% a Likert score. The indications of multiparametric-MRI were tumor detection/location prior to repeat biopsy (90%), cancer staging (85%), management of patients under active surveillance (85%), selection of candidates to focal therapy (63%), tumor detection/location in biopsy naïve patients (53%), detection of local recurrence after radical (51%). Only 119xa0urologists (28.6%) had access to image fusion (MRI and transrectal ultrasound) and 351 (85.4%) used cognitive fusion. Mostly, targeted biopsies are done by urologists alone (nearly 80%), a very few are done by radiologists (8%) or by the two of them in collaboration (12%).nnnCONCLUSIONnThe majority of urologists consider that prostate MRI is essential for the management of patients with prostate cancer. Practices are ahead of recommendations particularly before the first biopsy and in active surveillance.

Resultados funcionales de la pieloplastia laparoscópica pura y asistida por robot

Resumen El tratamiento del sindrome de la union pieloureteral (UPU) ha evolucionado considerablemente durante los ultimos 20 anos gracias a la aparicion de las nuevas tecnicas quirurgicas. Tradicionalmente, el tratamiento del sindrome de la UPU se basaba en la pieloplastia mediante cirugia abierta que, actualmente, continua siendo el tratamiento de referencia. Se han desarrollado, asimismo, alternativas quirurgicas entre las que se encuentra la endopielotomia, aunque con resultados inferiores. De esta forma, la via laparoscopica ha experimentado un auge en esta indicacion. La pieloplastia laparoscopica presenta indices de efectividad que suelen rozar el 95% y ofrece las ventajas de un postoperatorio mas llevadero y estancias hospitalarias mas cortas. No obstante, esta tecnica es de dificil acceso para la mayoria si se tiene en cuenta las dificultades tecnicas y las limitaciones que tiene el cirujano. La curva de aprendizaje puede llegar a ser, por lo tanto, desalentadora. Desde el ano 2000, la robotica se ha desarrollado de forma paralela, con resultados funcionales tan satisfactorios como los obtenidos en la laparoscopia pura. El robot es mas accesible para el cirujano, ya que resulta mas ergonomico y la tecnica de sutura parece mas reproducible. Sin embargo, el mayor obstaculo para la difusion de esta tecnica es su coste, aun elevado, especialmente en tratamientos de afecciones raras, como es el caso del sindrome de la UPU. Los indices de efectividad obtenidos con el robot son superiores al 95%, tanto radiologicos como clinicos.

Prise en charge carcinologique des cancers du pénis. Expérience d’un centre

Resume Objectif Les tumeurs malignes du penis sont rares et leur prise en charge complexe. Notre objectif etait de rapporter notre experience et de faire le point sur l’attitude therapeutique et les resultats carcinologiques. Materiels et methodes Les cas de cancers du penis suivis dans notre service entre 2000 et 2006 ont ete revus retrospectivement. Les donnees suivantes ont ete relevees : mode de revelation, bilan d’extension, localisation, anatomopathologie, stade TNM, traitement, evolution et survie. Resultats Au total, 7 cas de carcinomes epidermoides du penis ont ete diagnostiques. L’âge moyen des patients etait de 58,8 ans (41-74). Deux lesions pre-cancereuses ont ete retrouvees (maladie de Bowen) et une infection par le Human Papilloma Virus (HPV). Cinq patients ont eu un traitement conservateur multimodal et 2 patients ont eu une amputation totale de la verge. Quatre patients sont actuellement decedes. Le delai moyen de survie etait de 19,3 mois. La survie specifique a 5 ans a ete de 42,8%. Conclusion Les cancers du penis ont ete des tumeurs agressives et de mauvais pronostic. Les reunions de concertation pluri-disciplinaires trouvent tout leur interet dans ces cas de cancers rares ou la decision therapeutique, mal codifiee, merite d’etre prise de facon collegiale.

Dynamic contrast-enhanced imaging in localizing local recurrence of prostate cancer after radiotherapy: Limited added value for readers of varying level of experience: DCE in Localizing PCa Recurrence After RT

The incremental value of dynamic contrast‐enhanced (DCE) imaging in localizing radiorecurrent prostate cancer is uncertain.

Multiparametric MRI for Suspected Recurrent Prostate Cancer after HIFU:Is DCE still needed?

PurposeTo assess the added value of the dynamic contrast-enhanced sequence (DCE) to combination T2-weighted imaging (T2w) + diffusion-weighted imaging (DWI) in detecting prostate cancer (PCa) recurrence after HIFU (high-intensity focused ultrasound).MethodsForty-five males with clinical and biological suspected PCa recurrence were retrospectively selected. All underwent multi-parametric MRI (mpMRI) before biopsies. Two readers independently assigned a Likert score of cancer likelihood on T2w + DWI + DCE and T2w + DWI images. Prostatic biopsies were taken as the gold standard.ResultsRecurrent PCa was identified at biopsy for 37 patients (82%). Areas under the receiver-operating curve of T2w + DWI and T2w + DWI + DCE imaging were not significantly different for both readers. Using a Likert score ≥ 3 for the PCa diagnosis threshold, sensitivity at the lobe level for the (1) senior and (2) junior reader for T2w +DWI +DCE sensitivity was (1) 0.97 and (2) 0.94 vs. (1) 0.94 and (2) 0.97 for T2w + DWI.ConclusionAccuracy of mpMRI was not significantly improved by adding DCE to T2w + DWI. Sensitivity was high for T2w + DWI + DCE and T2w + DWI with no significant difference for either the junior or senior reader.Key Points• MpMRI has the capability to detect PCa recurrence in post-HIFU monitoring.• The sensitivity of T2w and DWI for detecting PCa recurrence was not improved by DCE.• Readers with different degrees of experience did not improve their performance with DCE.

Functional outcomes after pure laparoscopic or robot-assisted pyeloplasty

The management of ureteropelvic junction (UPJ) obstruction has evolved over the past 20 years in response to the development of new technology. Open surgery is still the reference standard against which all other surgical interventions must be measured. The surgical approach has, however, gone through rapid changes, and the open procedure initially described has evolved considerably. Endoscopic and laparoscopic approaches have largely supplanted open pyeloplasty for the majority of primary ureteropelvic junction obstruction cases. Laparoscopic approaches provide a balance between a highly successful technique in all patients and improved postoperative recovery. It has been shown to improve postoperative outcomes with shorter recovery times and hospital stays, and to provide equivalent functional results with a success rate of 95%. Nevertheless, laparoscopic pyeloplasty is not a simple procedure. There are a certain number of disadvantages, such as the limited range of laparoscopic instrument movement, the two dimensional image, the unfamiliar hand-eye coordination and the relatively inefficient ergonomic position. Since 2000, however, robots have provided a magnified three-dimensional view giving a greater degree of freedom. This system has simplified suturing and has improved precision of the operating technique. However, the system is very expensive and, providing it is available in their institution, it seems easier for beginners to learn the robotic technique. Additionally, it has similar success rates (both radiological and clinical) to those obtained with open techniques.

Tratamiento de las pielonefritis complicadas y de los abscesos renales

Las pielonefritis agudas complicadas (PNA secundarias) pueden aparecer de entrada o durante la evolucion de una PNA. Las distintas complicaciones son los abscesos renales, el absceso perinefritico, la pionefrosis, la pielonefritis enfisematosa, la pielonefritis xantogranulomatosa, la malacoplasia renal y la pielonefritis cronica. Los cuadros clinicos son variables y van del dolor lumbar al shock septico. El diagnostico se basa en la mayoria de las ocasiones en la tomografia computarizada (TC) con contraste. La evolucion de las formas complicadas siempre es grave si no se aplica tratamiento. Este, que suele ser urgente, consiste en antibioticos adecuados y medidas de reanimacion. A veces se asocia a un tratamiento quirurgico especifico.

Editorial Comment: Advances in MRI and PET of the prostate: concurrence or complementarity?

This Editorial Comment refers to the articles “Diagnostic evaluation of magnetization transfer and diffusion kurtosis imaging for prostate cancer detection in a re-biopsy population” by Barrett T et al., Eur Radiol. 2017 Dec 8 and “18F-Fluciclovine PET/MRI for preoperative lymph node staging in high-risk prostate cancer patients” by Selnæs KM et al., Eur Radiol. 2018 Jan 2.

Transition zone and anterior stromal prostate cancers: Evaluation of discriminant location criteria using multiparametric fusion-guided biopsy

PURPOSEnThe purpose of this study was to evaluate precise location criteria on magnetic resonance imaging (MRI) to improve detection of transition zone (TZ) and anterior stroma (AS) prostate cancers using targeted MRI/transrectal ultrasound fusion biopsies as a reference standard.nnnMATERIAL AND METHODSnNinety-six men (mean age: 65 years±7.7 [SD] [range: 46-83 years]) with an elevated prostate-specific antigen (PSA) (PSA≥4ng/mL) who underwent standard and targeted biopsies on a TZ/AS suspicious lesion were included. The database was reviewed to assess topographical and morphological features of each suspicious lesion on MR images (T2-weighted anatomical images on 1.5T MRI or 3T) including PI-RADS score assessed by a senior radiologist. Histopathological examination of MRI-transrectal ultrasound fusion biopsy specimens was used as the reference standard.nnnRESULTSnNinety patients had a positive targeted biopsy with a median [IQR] lesion size of 16mm [13-20mm]. Homogeneous hypointensity on T2-weighted mages, lenticular shape, lack of capsule and indistinct margins were present in 77/90 (85%) patients. All TZ/AS prostate cancers were located in the anterior half of the prostate: 3% at the base, 69% in the mid gland and 28% at the apex. Lesions were mainly located close to or within the AS (74%) and more rarely laterally compressed close to the peripheral anterior horn.nnnCONCLUSIONnOur results suggest that specific topographic criteria of TZ and AS prostate cancers could add independent information to the usual diagnostic criteria in prostate MRI. Transrectal ultrasound fusion-targeted biopsies based on these specific criteria improve volume estimation of prostate cancers with substantial impact for prognosis and treatment planning.

Characterization of small (<4 cm) solid renal masses by computed tomography and magnetic resonance imaging: Current evidence and further development

Diagnosis of renal cell carcinomas (RCC) subtypes on computed tomography (CT) and magnetic resonance imaging (MRI) is clinically important. There is increased evidence that confident imaging diagnosis is now possible while standardization of the protocols is still required. Fat-poor angiomyolipoma show homogeneously increased unenhanced attenuation, homogeneously low signal on T2-weighted MRI and apparent diffusion coefficient (ADC) map, may contain microscopic fat and are classically avidly enhancing. Papillary RCC are also typically hyperattenuating and of low signal on T2-weighted MRI and ADC map; however, their gradual progressive enhancement after intravenous administration of contrast material is a differentiating feature. Clear cell RCC are avidly enhancing and may show intracellular lipid; however, these tumors are heterogeneous and are of characteristically increased signal on T2-weighted MRI. Oncocytomas and chromophobe tumors (collectively oncocytic neoplasms) show intermediate imaging findings on CT and MRI and are the most difficult subtype to characterize accurately; however, both show intermediately increased signal on T2-weighted with more gradual enhancement compared to clear cell RCC. Chromophobe tumors tend to be more homogeneous compared to oncocytomas, which can be heterogeneous, but other described features (e.g. scar, segmental enhancement inversion) overlap considerably between tumors. Tumor grade is another important consideration in small solid renal masses with emerging studies on both CT and MRI suggesting that high grade tumors may be separated from lower grade disease based upon imaging features.