Suzanne Palmer

Standards of Reporting for MRI-targeted Biopsy Studies (START) of the Prostate: Recommendations from an International Working Group.

BACKGROUND A systematic literature review of magnetic resonance imaging (MRI)-targeted prostate biopsy demonstrates poor adherence to the Standards for the Reporting of Diagnostic Accuracy (STARD) recommendations for the full and transparent reporting of diagnostic studies. OBJECTIVE To define and recommend Standards of Reporting for MRI-targeted Biopsy Studies (START). DESIGN, SETTING, AND PARTICIPANTS Each member of a panel of 23 experts in urology, radiology, histopathology, and methodology used the RAND/UCLA appropriateness methodology to score a 258-statement premeeting questionnaire. The collated responses were presented at a face-to-face meeting, and each statement was rescored after group discussion. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Measures of agreement and consensus were calculated for each statement. The most important statements, based on group median score, the degree of group consensus, and the content of the group discussion, were used to create a checklist of reporting criteria (the START checklist). RESULTS AND LIMITATIONS The strongest recommendations were to report histologic results of standard and targeted cores separately using Gleason score and maximum cancer core length. A table comparing detection rates of clinically significant and clinically insignificant disease by targeted and standard approaches should also be used. It was recommended to report the recruitment criteria for MRI-targeted biopsy, prior biopsy status of the population, a brief description of the MRI sequences, MRI reporting method, radiologist experience, and image registration technique. There was uncertainty about which histologic criteria constitute clinically significant cancer when the prostate is sampled using MRI-targeted biopsy, and it was agreed that a new definition of clinical significance in this setting needed to be derived in future studies. CONCLUSIONS Use of the START checklist would improve the quality of reporting in MRI-targeted biopsy studies and facilitate a comparison between standard and MRI-targeted approaches.

3-Dimensional Elastic Registration System of Prostate Biopsy Location by Real-Time 3-Dimensional Transrectal Ultrasound Guidance With Magnetic Resonance/Transrectal Ultrasound Image Fusion

PURPOSE We determined the accuracy of the novel Urostation 3-dimensional transrectal ultrasound system (Koelis, La Tranche, France) for image based mapping biopsies in a prostate phantom. The system is capable of 1) registering the 3-dimensional location of each biopsy track in the 3-dimensional prostate volume data and 2) performing elastic image fusion of transrectal ultrasound with magnetic resonance imaging. MATERIALS AND METHODS We used 3 CIRS-053 prostate phantoms containing 3 hypoechoic lesions to perform ultrasound guided biopsy and 3 CIRS-066 phantoms (Computerized Imaging Reference Systems, Norfolk, Virginia) containing 3 isoechoic but magnetic resonance imaging visible lesions to perform magnetic resonance fusion guided biopsy. Three targeted biopsies were done per lesion. Each biopsy tract was injected with gadolinium based magnetic resonance contrast mixed with india ink. Phantoms were then subjected to 1 mm slice magnetic resonance imaging and serial step sectioning to assess the accuracy of targeted biopsy. RESULTS A total of 27 ultrasound guided biopsies were targeted into 9 hypoechoic lesions. All 27 biopsies (100%) successfully hit the target lesion. For hypoechoic lesions mean ± SD procedural targeting error was 1.52 ± 0.78 mm and system registration error was 0.83 mm, resulting in an overall error of 2.35 mm. Of the 27 magnetic resonance fusion biopsies 24 (84%) hit the lesion. For isoechoic lesions mean procedural targeting error was 2.09 ± 1.28 mm, resulting in an overall error of 2.92 mm. CONCLUSIONS The novel, computer assisted, 3-dimensional transrectal ultrasound biopsy localization system achieved encouraging accuracy with less than 3 mm error for targeting hypoechoic and isoechoic lesions. The ability to register actual biopsy trajectory and perform elastic magnetic resonance/ultrasound image fusion is a significant advantage for future focal therapy application.

Magnetic Resonance Imaging–Transectal Ultrasound Image-fusion Biopsies Accurately Characterize the Index Tumor: Correlation with Step-sectioned Radical Prostatectomy Specimens in 135 Patients

BACKGROUND Prostate biopsies targeted by elastic fusion of magnetic resonance (MR) and three-dimensional (3D) transrectal ultrasound (TRUS) images may allow accurate identification of the index tumor (IT), defined as the lesion with the highest Gleason score or the largest volume or extraprostatic extension. OBJECTIVE To determine the accuracy of MR-TRUS image-fusion biopsy in characterizing ITs, as confirmed by correlation with step-sectioned radical prostatectomy (RP) specimens. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of 135 consecutive patients who sequentially underwent pre-biopsy MR, MR-TRUS image-fusion biopsy, and robotic RP at two centers between January 2010 and September 2013. INTERVENTION Image-guided biopsies of MR-suspected IT lesions were performed with tracking via real-time 3D TRUS. The largest geographically distinct cancer focus (IT lesion) was independently registered on step-sectioned RP specimens. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS A validated schema comprising 27 regions of interest was used to identify the IT center location on MR images and in RP specimens, as well as the location of the midpoint of the biopsy trajectory, and variables were correlated. RESULTS AND LIMITATIONS The concordance between IT location on biopsy and RP specimens was 95% (128/135). The coefficient for correlation between IT volume on MRI and histology was r=0.663 (p<0.001). The maximum cancer core length on biopsy was weakly correlated with RP tumor volume (r=0.466, p<0.001). The concordance of primary Gleason pattern between targeted biopsy and RP specimens was 90% (115/128; κ=0.76). The study limitations include retrospective evaluation of a selected patient population, which limits the generalizability of the results. CONCLUSION Use of MR-TRUS image fusion to guide prostate biopsies reliably identified the location and primary Gleason pattern of the IT lesion in >90% of patients, but showed limited ability to predict cancer volume, as confirmed by step-sectioned RP specimens. PATIENT SUMMARY Biopsies targeted using magnetic resonance images combined with real-time three-dimensional transrectal ultrasound allowed us to reliably identify the spatial location of the most important tumor in prostate cancer and characterize its aggressiveness.

Beyond Hemostasis: Spectrum of Gynecologic and Obstetric Indications for Transcatheter Embolization

Percutaneous vascular embolization is a useful therapeutic option for a wide range of gynecologic and obstetric abnormalities. Transcatheter embolization procedures performed with the use of radiologic imaging for guidance are minimally invasive and may obviate surgery, thereby decreasing morbidity and mortality and safeguarding the patients future fertility potential. To integrate this treatment method optimally into patient care, knowledge is needed about the clinical indications for therapeutic embolization, the relevant vascular anatomy, technical considerations of the procedure, and the potential risks and benefits of embolization. The most well-known and well-studied transcatheter embolization technique for treating a gynecologic-obstetric condition is uterine fibroid embolization. However, the clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as adenomyosis and arteriovenous malformations, as well as intractable bleeding due to inoperable advanced-stage malignancies. Uterine artery embolization may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage, placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury, and ovarian vein embolization has been shown to be effective for the management of pelvic congestion syndrome. The article discusses these and other gynecologic and obstetric indications for transcatheter embolization, provides detailed descriptions of imaging findings before and after embolization, and reviews procedural techniques and outcomes.

Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study

OBJECTIVE The purpose of this study was to determine the diagnostic performance of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis during pregnancy in a multiinstitutional study. STUDY DESIGN In this multicenter retrospective study, the cases of pregnant women who underwent MRI evaluation of abdominal or pelvic pain and who had clinical suspicion of acute appendicitis between June 1, 2009, and July 31, 2014, were reviewed. All MRI examinations with positive findings for acute appendicitis were confirmed with surgical pathologic information. Sensitivity, specificity, negative predictive values, and positive predictive values were calculated. Receiver operating characteristic curves were generated, and area under the curve analysis was performed for each participating institution. RESULTS Of the cases that were evaluated, 9.3% (66/709) had MRI findings of acute appendicitis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values were 96.8%, 99.2%, 99.0%, 92.4%, and 99.7%, respectively. There was no statistically significant difference between centers that were included in the study (pair-wise probability values ranged from 0.12-0.99). CONCLUSION MRI is useful and reproducible in the diagnosis of suspected acute appendicitis during pregnancy.

Iatrogenic Pseudoaneurysms of the Extrahepatic Arterial Vasculature: Management and Outcome

BACKGROUND Pseudoaneurysms of the extrahepatic arterial vasculature are relatively uncommon lesions following surgery and trauma. In this report we analyze the presentation, management and outcomes of these vascular lesions. Of the related surgical procedures, the reported incidence is highest following laparoscopic cholecystectomy. We hereby analyze the literature on this subject and report our experience, specifically with extrahepatic pseudoaneurysms, drawing an important distinction from intrahepatic pseudoaneurysms. METHODS From September 1995 until July 2004, six patients, including three males and three females with a mean age of 67 years, were treated for seven extrahepatic arterial pseudoaneurysms. Patients were evaluated by endoscopy, ultrasound, computerized tomography, and angiography. Management included coil embolization or arterial ligation and/or hepatic resection. RESULTS The mean pseudoaneurysm size was 4.9-cm (range 1.0-11.0-cm) and the locations included the right hepatic artery (n = 5), inferior pancreaticoduodenal artery (n = 1), and gastroduodenal artery (n = 1). All six patients had prior surgical or percutaneous procedures. Median latency period between the original procedure and treatment of pseudoaneurysm was 17 weeks (range one month-16 years). Clinical features ranged from the dramatic presentation of hypotension secondary to intraperitoneal aneurysmal rupture to the subtle presentation of obstructive jaundice secondary to pseudoaneurysm mass effect. The range of patient presentations created diagnostic challenges, proving that accurate diagnosis is made only by early consideration of pseudoaneurysm. Management was ligation of the right hepatic artery (n = 4) and embolization of the pseudoaneurysms (n = 2). Post-treatment sequelae included liver failure requiring liver transplant (n = 1), intrahepatic biloma requiring percutaneous drainage (n = 1) and cholangitis with right hepatic duct strictures requiring right lobectomy and biliary reconstruction (n = 1). These complications followed arterial ligation, with no complications resulting from embolization. All six patients are alive and well after a mean follow-up of 53 months. CONCLUSIONS Our six patients demonstrate the diversity and unpredictability with which a pseudoaneurysm of the extrahepatic arterial vasculature may present in terms of initial symptoms, prior procedures, and the latency period between presentation and prior procedure. Through our experience and an analysis of the literature, we recommend a diagnostic and management approach for these patients.

Prostate Cancer Volume Estimation by Combining Magnetic Resonance Imaging and Targeted Biopsy Proven Cancer Core Length: Correlation with Cancer Volume

PURPOSE Multiparametric magnetic resonance imaging often underestimates or overestimates pathological cancer volume. We developed what is to our knowledge a novel method to estimate prostate cancer volume using magnetic resonance/ultrasound fusion, biopsy proven cancer core length. MATERIALS AND METHODS We retrospectively analyzed the records of 81 consecutive patients with magnetic resonance/ultrasound fusion, targeted biopsy proven, clinically localized prostate cancer who underwent subsequent radical prostatectomy. As 7 patients each had 2 visible lesions on magnetic resonance imaging, 88 lesions were analyzed. The dimensions and estimated volume of visible lesions were calculated using apparent diffusion coefficient maps. The modified formula to estimate cancer volume was defined as the formula of vertical stretching in the anteroposterior dimension of the magnetic resonance based 3-dimensional model, in which the imaging estimated lesion anteroposterior dimension was replaced by magnetic resonance/ultrasound targeted, biopsy proven cancer core length. Agreement of pathological cancer volume with magnetic resonance estimated volume or the novel modified volume was assessed using a Bland-Altman plot. RESULTS Magnetic resonance/ultrasound fusion, biopsy proven cancer core length was a stronger predictor of the actual pathological cancer anteroposterior dimension than magnetic resonance estimated lesion anteroposterior dimension (r = 0.824 vs 0.607, each p <0.001). Magnetic resonance/ultrasound targeted, biopsy proven cancer core length correlated with pathological cancer volume (r = 0.773, p <0.001). The modified formula to estimate cancer volume demonstrated a stronger correlation with pathological cancer volume than with magnetic resonance estimated volume (r = 0.824 vs 0.724, each p <0.001). Agreement of modified volume with pathological cancer volume was improved over that of magnetic resonance estimated volume on Bland-Altman plot analysis. Predictability was more enhanced in the subset of lesions with a volume of 2 ml or less (ie if spherical, the lesion was approximately 16 mm in diameter). CONCLUSIONS Combining magnetic resonance estimated cancer volume with magnetic resonance/ultrasound fusion, biopsy proven cancer core length improved cancer volume predictability.

Sensitivity of Myoma Imaging Using Laparoscopic Ultrasound Compared With Magnetic Resonance Imaging and Transvaginal Ultrasound

STUDY OBJECTIVE To determine the efficacy of laparoscopic ultrasound (LUS) as compared with contrast-enhanced magnetic resonance imaging (CE-MRI) and transvaginal ultrasound (TVUS) in detection of uterine myomas. DESIGN Retrospective study of imaging methods used in a trial of LUS-guided radiofrequency volumetric thermal ablation in women with symptomatic myomas (Canadian Task Force classification II-2). SETTING Eleven medical university or private outpatient surgery clinics in the United States (nine sites) and Latin America (two sites). PATIENTS One hundred thirty-five women with symptomatic myomas and objectively confirmed moderate to severe heavy menstrual bleeding. INTERVENTIONS LUS-guided radiofrequency volumetric thermal ablation of myomas. MEASUREMENTS AND MAIN RESULTS Preoperative TVUS scans and CE-MRIs were read at each site, and all CE-MRIs were read by a central reader. LUS-guided scans were obtained intraoperatively by each surgeon by mapping the uterus just before radiofrequency volumetric thermal ablation. The imaging methods and their yields in terms of number of myomas found per subject were as follows: TVUS, 403 myomas (mean [SD] 3 [1.8]; range, 1-8); site CE-MRI, 562 myomas (4.2 [3.8]; range, 1-18); central reader, 619 myomas (4.6 [3.7]; range, 0-20); and LUS, 818 myomas (6.1 [4.9]; range, 1-29) (p < .001). LUS was superior to TVUS, CE-MRI, and the central reader for detection of small (≤1 cm(3)) myomas. Most imaged myomas were intramural: 197 (50.9%) by TVUS, 298 (55.5%) by site CE-MRI, 290 (48.7%) by the central reader, and 386 (48.5%) by LUS. CONCLUSION Compared with CE-MRI and TVUS, LUS demonstrates the most myomas, regardless of size or type.

Dyspnea lusoria: compression of the pulmonary artery by a Kommerell’s diverticulum

We report a rare case of Kommerells diverticulum presenting as dyspnea on exertion. After careful physical examination, selective imaging tests demonstrated a significant flow abnormality in the left pulmonary artery caused by an aneurysm of the descending aorta in the area of the ligamentum arteriosum.

CT-Guided Tube Pericardiostomy: A Safe and Effective Technique in the Management of Postsurgical Pericardial Effusion

OBJECTIVE The purpose of this study was to analyze the efficacy and examine the competitive cost of CT-guided tube pericardiostomy in the management of symptomatic postsurgical pericardial effusion. MATERIALS AND METHODS Over a 4-year period, 36 patients with symptomatic pericardial effusion were treated with CT-guided percutaneous placement of an indwelling pericardial catheter, for a total of 39 CT-guided tube pericardiostomy procedures. Thirty-three patients (92%) had undergone major cardiothoracic surgery, and three patients (8%) had undergone minimally invasive procedures. The medical records were retrospectively reviewed for clinical presentation, surgical history, imaging studies performed, procedural details, fluid characterization, and outcome. Charge comparison was performed with the American Medical Association Current Procedural Terminology codes and information acquired from the billing department at our facility. RESULTS All 39 CT-guided tube pericardiostomy procedures were performed successfully without clinically significant complications. After 33 of the 39 procedures (85%), symptoms did not recur after the catheter was removed. Three of 36 patients (8%) had a recurrence of pericardial effusion. Comparison of procedure charges showed an 89% saving over intraoperative pericardial window procedures and no significant difference compared with ultrasound-guided tube pericardiostomy. Eight patients (21% of procedures) needed pleural drainage procedures, all of which were performed in the CT suite immediately after the tube pericardiostomy procedure. CONCLUSION CT-guided tube pericardiostomy is a safe and effective alternative to surgical drainage in the care of patients with clinically significant pericardial effusion after cardiothoracic surgery and has the additional benefit of substantial cost savings.