The Incremental Role of Magnetic Resonance Imaging for Prostate Cancer Staging before Radical Prostatectomy

In the present report we aimed to analyze the incremental value of preoperative magnetic resonance imaging (MRI), in addition to clinical variables and clinically-derived nomograms, in predicting outcomes radical prostatectomy (RP). All Mayo Clinic RP patients who underwent preoperative 1.5-Tesla MRI with endo-rectal coil from 2003 to 2013 were identified. Clinical and histopathological variables were used to calculate Partin estimates and Cancer of the Prostate Risk Assessment (CAPRA) score. MRI results in terms of extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymph-node invasion (N+) were recorded. Using RP pathology as gold standard, we developed multivariate logistic regression models based on clinical variables, Partin Tables, and CAPRA score, and assessed their predictive accuracy before and after the addition of MRI results. Five hundred and one patients were included. MRI + clinical models outperformed clinical-based models alone for all outcomes. Comparing Partin and Partin + MRI predictive models, the areas under the curve were 0.61 versus 0.73 for ECE, 0.75 versus 0.82 for SVI, and 0.82 versus 0.85 for N+. Comparing CAPRA and CAPRA + MRI models, the areas under the curve were 0.69 versus 0.77 for ECE, 0.75 versus 0.83 for SVI, and 0.82 versus 0.85 for N+. Our data show that MRI can improve clinical-based models in prediction of nonorgan confined disease, particularly for ECE and SVI

Detection of recurrent prostate cancer after primary radiation therapy: An evaluation of the role of multiparametric 3T magnetic resonance imaging with endorectal coil

Objectives: The value of multiparametric magnetic resonance imaging (mpMRI) in staging prostate cancer (PCa) before salvage prostatectomy is currently unclear because of the minimal data comparing mpMRI results to final pathologic stage at surgery. The aim of the study is to determine the diagnostic performance of mpMRI in characterizing viable recurrent tumor and lymph node metastasis following radiation therapy (RT) failure. Methods and materials: Between January 2007 and July 2014, 19 patients with biopsy-proven recurrent PCa after primary RT underwent 3T mpMRI and subsequent salvage prostatectomy with extended pelvic lymphadenectomy. mpMRI images were independently reviewed by 2 genitourinary MRI radiologists (R1 and R2), blinded to the pathology results, to evaluate extraprostatic extension (EPE), seminal vesicle invasion (SVI), and pelvic lymph node metastasis (PLNM). Sensitivity, specificity, positive predictive value, negative predictive value, receiver operating characteristic curves, and interobserver agreement (R1 and R2) were evaluated for each outcome on a per-patient basis. Final pathologic results were used as a gold standard for comparison in all patients. A multivariate analysis was conducted to assess the relationship between the index lesion's apparent diffusion coefficient value and its enhancement characteristics with the Gleason score. Results: EPE was found in 14 (73.7%) patients, SVI in 13 (68.4%), and PLNMin 5 (26.3%). mpMRI sensitivity for PLNM was 60.0% (R1 and R2) with specificity of 85.7% (R1) and 92.8% (R2). With regards to SVI, the sensitivity was 61.5% (R1) and 76.9% (R2), with a specificity of 66.6% (R1 and R2). Sensitivity for EPE was 50.0% (R1) and 71.43% (R2), with a specificity of 80.0% (R1) and 100.00% (R2). No significant associations were found at multivariate analysis. The evaluation of PLNM, SVI, and PCa recurrence within the prostate demonstrated moderate interobserver agreement (kappa, 0.51-0.57). Conclusions: mpMRI has good accuracy for detecting PLNM, SVI, and EPE after RT. mpMRI provides useful information in locally recurrent PCa following primary radiation therapy. (C) 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved

Interobserver Reproducibility of the PI-RADS Version 2 Lexicon: A Multicenter Study of Six Experienced Prostate Radiologists.

Purpose To determine the interobserver reproducibility of the Prostate Imaging Reporting and Data System (PI-RADS) version 2 lexicon. Materials and Methods This retrospective HIPAA-compliant study was institutional review board-approved. Six radiologists from six separate institutions, all experienced in prostate magnetic resonance (MR) imaging, assessed prostate MR imaging examinations performed at a single center by using the PI-RADS lexicon. Readers were provided screen captures that denoted the location of one specific lesion per case. Analysis entailed two sessions (40 and 80 examinations per session) and an intersession training period for individualized feedback and group discussion. Percent agreement (fraction of pairwise reader combinations with concordant readings) was compared between sessions. κ coefficients were computed. Results No substantial difference in interobserver agreement was observed between sessions, and the sessions were subsequently pooled. Agreement for PI-RADS score of 4 or greater was 0.593 in peripheral zone (PZ) and 0.509 in transition zone (TZ). In PZ, reproducibility was moderate to substantial for features related to diffusion-weighted imaging (κ = 0.535-0.619); fair to moderate for features related to dynamic contrast material-enhanced (DCE) imaging (κ = 0.266-0.439); and fair for definite extraprostatic extension on T2-weighted images (κ = 0.289). In TZ, reproducibility for features related to lesion texture and margins on T2-weighted images ranged from 0.136 (moderately hypointense) to 0.529 (encapsulation). Among 63 lesions that underwent targeted biopsy, classification as PI-RADS score of 4 or greater by a majority of readers yielded tumor with a Gleason score of 3+4 or greater in 45.9% (17 of 37), without missing any tumor with a Gleason score of 3+4 or greater. Conclusion Experienced radiologists achieved moderate reproducibility for PI-RADS version 2, and neither required nor benefitted from a training session. Agreement tended to be better in PZ than TZ, although was weak for DCE in PZ. The findings may help guide future PI-RADS lexicon updates. (©) RSNA, 2016 Online supplemental material is available for this article

A Collaborative Multidisciplinary Approach to the Management of Coronavirus Disease 2019 in the Hospital Setting.

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which presents an unprecedented challenge to medical providers worldwide. Although most SARS-CoV-2-infected individuals manifest with a self-limited mild disease that resolves with supportive care in the outpatient setting, patients with moderate to severe COVID-19 will require a multidisciplinary collaborative management approach for optimal care in the hospital setting. Laboratory and radiologic studies provide critical information on disease severity, management options, and overall prognosis. Medical management is mostly supportive with antipyretics, hydration, oxygen supplementation, and other measures as dictated by clinical need. Among its medical complications is a characteristic proinflammatory cytokine storm often associated with end-organ dysfunction, including respiratory failure, liver and renal insufficiency, cardiac injury, and coagulopathy. Specific recommendations for the management of these medical complications are discussed. Despite the issuance of emergency use authorization for remdesivir, there are still no proven effective antiviral and immunomodulatory therapies, and their use in COVID-19 management should be guided by clinical trial protocols or treatment registries. The medical care of patients with COVID-19 extends beyond their hospitalization. Postdischarge follow-up and monitoring should be performed, preferably using telemedicine, until the patients have fully recovered from their illness and are released from home quarantine protocols

Repeatability and Reproducibility Assessment of the Apparent Diffusion Coefficient in the Prostate: A Trial of the ECOG-ACRIN Research Group (ACRIN 6701)

Background Uncertainty regarding the reproducibility of the apparent diffusion coefficient (ADC) hampers the use of quantitative diffusion-weighted imaging (DWI) in evaluation of the prostate with magnetic resonance imaging MRI. The quantitative imaging biomarkers alliance (QIBA) profile for quantitative DWI claims a within-subject coefficient of variation (wCV) for prostate lesion ADC of 0.17. Improved understanding of ADC reproducibility would aid the use of quantitative diffusion in prostate MRI evaluation. Purpose Evaluation of the repeatability (same-day) and reproducibility (multi-day) of whole-prostate and focal-lesion ADC assessment in a multi-site setting. Study Type Prospective multi-institutional. Subjects Twenty-nine males, ages 53 to 80 (median 63) years, following diagnosis of prostate cancer, 10 with focal lesions. Field Strength/Sequence 3T, single-shot spin-echo diffusion-weighted echo-planar sequence with four b-values. Assessment Sites qualified for the study using an ice-water phantom with known ADC. Readers performed DWI analyses at visit 1 (V1) and visit 2 (V2, 2-14 days after V1), where V2 comprised scans before (V2pre) and after (V2post) a coffee-break interval with subject removal and repositioning. A single reader segmented the whole prostate. Two readers separately placed region-of-interests for focal lesions. Statistical Tests Reproducibility and repeatability coefficients for whole prostate and focal lesions derived from median pixel ADC. We estimated the wCV and 95% confidence interval using a variance stabilizing transformation and assessed interreader reliability of focal lesion ADC using the intraclass correlation coefficient (ICC). Results The ADC biases from b(0)-b(600) and b(0)-b(800) phantom scans averaged 1.32% and 1.44%, respectively; mean b-value dependence was 0.188%. Repeatability and reproducibility of whole prostate median pixel ADC both yielded wCVs of 0.033 (N = 29). In 10 subjects with an evaluable focal lesion, the individual reader wCVs were 0.148 and 0.074 (repeatability) and 0.137 and 0.078 (reproducibility). All time points demonstrated good to excellent interreader reliability for focal lesion ADC (ICCV1 = 0.89; ICCV2pre = 0.76; ICCV2post = 0.94). Data Conclusion This study met the QIBA claim for prostate ADC. Test-retest repeatability and multi-day reproducibility were largely equivalent. Interreader reliability for focal lesion ADC was high across time points. Level of Evidence 1 Technical Efficacy Stage 2 TOC Category Pelvi

Impact of measurement method on interobserver variability of apparent diffusion coefficient of lesions in prostate MRI.

PurposeTo compare the inter-observer variability of apparent diffusion coefficient (ADC) values of prostate lesions measured by 2D-region of interest (ROI) with and without specific measurement instruction.MethodsForty lesions in 40 patients who underwent prostate MR followed by targeted prostate biopsy were evaluated. A multi-reader study (10 readers) was performed to assess the agreement of ADC values between 2D-ROI without specific instruction and 2D-ROI with specific instruction to place a 9-pixel size 2D-ROI covering the lowest ADC area. The computer script generated multiple overlapping 9-pixel 2D-ROIs within a 3D-ROI encompassing the entire lesion placed by a single reader. The lowest mean ADC values from each 2D-small-ROI were used as reference values. Inter-observer agreement was assessed using the Bland-Altman plot. Intraclass correlation coefficient (ICC) was assessed between ADC values measured by 10 readers and the computer-calculated reference values.ResultsTen lesions were benign, 6 were Gleason score 6 prostate carcinoma (PCa), and 24 were clinically significant PCa. The mean±SD ADC reference value by 9-pixel-ROI was 733 ± 186 (10-6 mm2/s). The 95% limits of agreement of ADC values among readers were better with specific instruction (±112) than those without (±205). ICC between reader-measured ADC values and computer-calculated reference values ranged from 0.736-0.949 with specific instruction and 0.349-0.919 without specific instruction.ConclusionInterobserver agreement of ADC values can be improved by indicating a measurement method (use of a specific ROI size covering the lowest ADC area)