Sidath H. Liyanage

Diagnostic accuracy of magnetic resonance imaging (MRI) prostate imaging reporting and data system (PI-RADS) scoring in a transperineal prostate biopsy setting

To determine the sensitivity and specificity of multiparametric magnetic resonance imaging (mpMRI) for significant prostate cancer with transperineal sector biopsy (TPSB) as the reference standard.

Radiologic presentation of chronic granulomatous prostatitis mimicking locally advanced prostate adenocarcinoma

We present a case of nonspecific granulomatous prostatitis (GP), a clinical mimic of prostate adenocarcinoma. A 54-year-old man presented with lower urinary tract symptoms and raised prostate-specific antigen. Magnetic resonance imaging showed features consistent with prostate cancer, including low T2-signal intensity in the peripheral and transition zones with signs of extracapsular extension. Diffusion-weighted imaging showed high-signal intensity, with low apparent diffusion coefficient values, whereas dynamic contrast enhancement demonstrated a type 3 washout curve, similar to that found in prostate cancer. Transperineal sector-guided prostate biopsy confirmed nonspecific GP, and the patient was treated conservatively. We discuss and compare nonspecific, chronic GP as a radiologic mimic of prostate adenocarcinoma patient.

Bifid ureter with blind-ending branch: A rare anatomic variant detected during antegrade ureteric stent insertion

Anatomic variants of the urinary tract are relatively common; however, a bifid ureter with a blind-ending branch is a rare congenital anomaly. This variant often goes unnoticed because patients are either asymptomatic or complain of vague abdominal symptoms. Diagnosis is often incidental, and may be missed on conventional imaging. Although bifid ureters usually do not require any specific investigations or treatment; it is important to have an appreciation for these anomalies particularly if radiological intervention or surgical procedures are planned. We describe a case of a blind-ending bifid ureter in a patient with bilateral hydronephrosis secondary to a large cervical malignancy. The presence of the bifid ureter was only appreciated during a technically challenging antegrade ureteric stent insertion several weeks after diagnosis. We review the clinical significance, embryology, and radiology findings of this anomaly, as well as the implications during radiological interventional procedures.

Toward an MRI-based nomogram for the prediction of transperineal prostate biopsy outcome: A physician and patient decision tool

PURPOSE To develop and internally validate a nomogram using biparametric magnetic resonance imaging (B-MRI)-derived variables for the prediction of prostate cancer at transperineal sector-guided prostate biopsy (TPSB). SUBJECTS/PATIENTS AND METHODS Consecutive patients referred to our institution with raised prostate-specific antigen (PSA), abnormal prostate examination, or persistent suspicion of prostate cancer after previous transrectal biopsy between July 2012 and November 2015 were reviewed from a prospective database. All patients underwent prebiopsy B-MRI with T2-weighted and diffusion-weighted imaging sequences, followed by 24 to 40 core TPSB with additional targeted cores using cognitive registration. Univariable and multivariable logistic regression analysis was used to determine predictors of prostate cancer outcomes. Multivariable coefficients were used to construct 2 MRI-based nomograms to predict any and significant (Gleason 4 or maximum cancer core length ≥6mm) prostate cancer at TPSB. Bootstrap resamples were used for internal validation. Accuracy was assessed by calculating the concordance index. RESULTS In total, 615 men were included in the study. Prostate cancer was diagnosed in 317 (51.5%) men with significant cancer diagnosed in 237 (38.5%) men. Age, Prostate Imaging Reporting and Data System (PI-RADS) score, PSA, PSA density, and primary biopsy were predictors of prostate cancer at TPSB on univariable analysis (P<0.0001). PSA showed strong correlation with PSA density and was excluded. The remaining variables were all independent predictors of prostate cancer on multivariable analysis (P<0.0001) and used to generate the nomograms. Both nomograms showed good discrimination for prostate cancer, with a concordance index of 87% for any cancer and 92% for significant disease. Using a nomogram-derived probability threshold of<15%, 111 (18.0%) biopsies can be saved, at the expense of 3 missed significant prostate cancers. CONCLUSIONS These internally validated MR-based nomograms were able to accurately predict TPSB outcomes for prostate cancer, especially significant disease. Our findings support the combination of prebiopsy MRI results and clinical factors as part of the biopsy decision-making process.

Triparametric ultrasound in differentiating multicystic renal masses: a rare presentation of unilateral focal renal lymphangioma

We describe a rare case of renal lymphangioma presenting as a focal unilateral multicystic renal mass and document the first reported use of triparametric ultrasound (B-mode, Doppler, and contrast-enhanced ultrasound) in its diagnosis and discrimination from other focal multicystic lesions. Renal lymphangiomas are rare, benign, typically developmental lesions composed of cystic dilatation of the lymphatic ducts, usually occurring bilaterally as perinephric collections or parapelvic cysts mimicking hydronephrosis. Radiologists have an important role in suggesting the diagnosis, as clinical presentation can be nonspecific. Management is usually conservative; however, nephron-sparing surgery may be recommended in symptomatic individuals.

Multiparametric ultrasound findings of tuberculous orchitis following bacillus Calmette-Guérin therapy

Granulomatous bacillus Calmette-Guérin (BCG) infection, both localized and disseminated, as a complication of intravesical therapy for transitional cell carcinoma of the bladder is a recognized but highly unusual phenomenon. We report the case of an 89-year-old gentleman with a history of bladder transitional cell carcinoma and subsequent intravesical BCG instillation of the bladder who presented to his general practitioner with a non-tender lump in his left testis. Histopathologic and microbiological evaluation of the subsequent orchidectomy specimen revealed granuloma formation secondary to BCG infection. The use of bubble contrast agents and elastography in ultrasound to evaluate focal testicular lesions is a relatively novel concept, and we aim to highlight the imaging features of testicular BCG infection using these techniques.

The CADMUS trial – Multi-parametric ultrasound targeted biopsies compared to multi-parametric MRI targeted biopsies in the diagnosis of clinically significant prostate cancer

OBJECTIVE To compare the proportion of clinically significant prostate cancers (PCa) found in lesions detected by multiparametric MRI (mpMRI) with that found in lesions detected by multiparametric ultrasound (mpUSS), in men at risk. PATIENTS AND METHODS CADMUS (Cancer Detection by Multiparametric Ultrasound of the prostate) is a prospective, multi-centre paired cohort diagnostic utility study with built-in randomisation of order of biopsies. The trial is registered ISRCTN38541912. All patients will undergo the index test under evaluation (mpUSS±biopsies), as well as the standard test (mpMRI±biopsies). Eligible men will be those at risk of harbouring prostate cancer usually recommended for prostate biopsy, either for the first time or as a repeat, who have not had any prior treatment for prostate cancer. Men in need of repeat biopsy will include those with prior negative results but ongoing suspicion, and those with an existing prostate cancer diagnosis but a need for accurate risk stratification. Both scans will be reported blind to the results of the other and the order in which the targeted biopsies derived from the two different imaging modalities are taken will be randomised. Comparison will be drawn between biopsy results of lesions detected by mpUSS with those lesions detected by mpMRI. Agreement over position between the two imaging modalities will be studied. DISCUSSION CADMUS will provide level one evidence on the performance of mpUSS derived targeted biopsies in the identification of clinically significant prostate cancer in comparison to mpMRI targeted biopsies. Recruitment is underway and expected to complete in 2018.