Publications by authors named "Adam T Froemming"

49 Publications

The prognostic value, sensitivity, and specificity of multiparametric magnetic resonance imaging before salvage radiotherapy for prostate cancer.

Radiother Oncol 2021 May 21;161:9-15. Epub 2021 May 21.

Department of Radiation Oncology, Mayo Clinic, Rochester, USA.

Aim: To determine the operational characteristics of pelvic magnetic resonance imaging (MRI) prior to salvage radiation therapy (SRT) for biochemically recurrent prostate cancer following radical prostatectomy.

Methods And Materials: We reviewed the medical records of 386 patients who underwent MRI prior to SRT. We assessed associations of pre-SRT MRI findings with biochemical recurrence (BCR), distant metastasis (DM), prostate cancer-specific mortality (PCSM), and salvage androgen deprivation therapy (ADT) use following SRT. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI for detecting local recurrence were also calculated.

Results: Pre-SRT MRI was positive for local recurrence in 216 patients (56%), indeterminate in 46 (12%), and negative in 124 (32%). On univariate analysis, BCR following SRT was significantly less likely for patients with positive (HR: 0.58, 95% CI: 0.42-0.8) or indeterminate (HR: 0.6: 0.36-1) MRI findings, compared to patients with negative imaging (p = 0.003). These associations remained significant on multivariate analysis (p < 0.05) and across pre-SRT PSA groups. For the entire cohort, the sensitivity of MRI for local recurrence was 61.0% (53.5-68.1%), specificity 60.0% (44.3-73.0%), PPV 86.1% (78.9-91.5%) and NPV 27.6% (19.0-37.5%). Sensitivity of MRI was better in men with higher pre-SRT PSA (80.0% for PSA > 1.0), and specificity was improved with lower pre-SRT PSA (73.9% for PSA 0.1-0.5).

Conclusions: Positive or indeterminate MRI findings prior to SRT were associated with improved biochemical control following SRT, across PSA levels. The sensitivity and specificity of MRI for local recurrence were 61% and 58.7%, respectively.
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http://dx.doi.org/10.1016/j.radonc.2021.05.015DOI Listing
May 2021

ACR Appropriateness Criteria® Post-Treatment Surveillance of Bladder Cancer: 2021 Update.

J Am Coll Radiol 2021 May;18(5S):S126-S138

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

Urothelial cancer is the second most common cancer, and cause of cancer death, related to the genitourinary tract. The goals of surveillance imaging after the treatment of urothelial cancer of the urinary bladder are to detect new or previously undetected urothelial tumors, to identify metastatic disease, and to evaluate for complications of therapy. For surveillance, patients can be stratified into one of three groups: 1) nonmuscle invasive bladder cancer with no symptoms or additional risk factors; 2) nonmuscle invasive bladder cancer with symptoms or additional risk factors; and 3) muscle invasive bladder cancer. This document is a review of the current literature for urothelial cancer and resulting recommendations for surveillance imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2021.02.011DOI Listing
May 2021

CT-derived sarcopenia should not preclude surgical stabilization of traumatic rib fractures.

Eur Radiol Exp 2021 Feb 16;5(1). Epub 2021 Feb 16.

Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Background: Rib fractures are associated with considerable morbidity and mortality. Surgical stabilization of rib fractures (SSRF) can be performed to mitigate complications. Sarcopenia is in general known to be associated with poor clinical outcomes. We investigated if sarcopenia impacted number of days of mechanical ventilation, intensive care unit (ICU) stay, and total hospital stay in patients who underwent SSRF.

Methods: A retrospective single institutional review was performed including patients who underwent SSRF (2009-2017). Skeletal muscle index (SMI) was semiautomatically calculated at the L3 spinal level on computed tomography (CT) images and normalized by patient height. Sarcopenia was defined as SMI < 55 cm/m in males and < 39 cm/m in females. Demographics, operative details, and postoperative outcomes were reviewed. Univariate and multivariate analyses were performed.

Results: Of 238 patients, 88 (36.9%) had sarcopenia. There was no significant difference in number of days of mechanical ventilation (2.8 ± 4.9 versus 3.1 ± 4.3, p = 0.304), ICU stay (5.9 ± 6.5 versus 4.9 ± 5.7 days, p = 0.146), or total hospital stay (13.3 ± 7.2 versus 12.9 ± 8.2 days, p = 0.183) between sarcopenic and nonsarcopenic patients. Sarcopenic patients demonstrated increased modified frailty index scores (1.5 ± 1.1 versus 0.9 ± 0.9, p < 0.001) compared to nonsarcopenic patients.

Conclusions: For patients who underwent SSRF for rib fractures, sarcopenia did not increase the number of days of mechanical ventilation, ICU stay, or total hospital stay. Sarcopenia should not preclude the utilization of SSRF in these patients.
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http://dx.doi.org/10.1186/s41747-021-00206-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884563PMC
February 2021

Prostate MRI characteristics in patients with inflammatory bowel disease.

Eur J Radiol 2021 Feb 5;135:109503. Epub 2021 Jan 5.

Mayo Clinic, Department of Radiology, Minnesota, USA. Electronic address:

Purpose: Previous studies have indicated an increased risk of prostate carcinoma (PCa) associated with inflammatory bowel disease (IBD). Prostate MRI of IBD patients could be expected to show a mixture of inflammation as well as higher than normal rates of PCa, which could impact interpretation and MRI performance. The purpose of this study is to evaluate the characteristics of prostate MRI in patients with IBD.

Methods: 3140 patients with prostate MRI were evaluated. Coexisting IBD, PI-RADS score, and pathological results of prostate lesions (clinically significant PCa [csPCa]: Gleason score [GS] 7+, Non-csPCa: benign or GS 6) were assessed. The distribution of PI-RADS scoring and pathological result was assessed by chi-square test.

Results: 71 patients had IBD (IBD group), whereas the remaining 3069 patients did not (Non-IBD group). The proportion of abnormal MRI (PI-RADS 3, 4 or 5) was 51 % (36/71) in IBD group and 47 % (1436/3069) in Non-IBD groups (p = 0.513). Total of 1285 patients underwent biopsy or prostatectomy. The proportion of csPCa at pathology was 35 % (12/34) in IBD group and 56 % (699/1251) in non-IBD groups (p = 0.017). The positive predictive value of abnormal MRI for csPCa was significantly lower in IBD group (39 %, 19/31) compared to Non-IBD group (63 %, 657/1047) (p = 0.007).

Conclusion: The proportion of csPCa at pathology and positive predictive value of abnormal MR for csPCa were lower in patients with IBD group compared to Non-IBD group.
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http://dx.doi.org/10.1016/j.ejrad.2020.109503DOI Listing
February 2021

ACR Appropriateness Criteria® Recurrent Lower Urinary Tract Infections in Females.

J Am Coll Radiol 2020 Nov;17(11S):S487-S496

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

Urinary tract infections (UTIs) in women are common, with an overall lifetime risk over >50%. UTIs are considered recurrent when they follow complete clinical resolution of a previous UTI and are usually defined as at least three episodes of infection within the preceding 12 months. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities. Complicated UTIs are those occurring in patients with underlying structural or medical problems. In women with recurrent uncomplicated UTIs, cystoscopy and imaging are not routinely used. In women suspected of having a recurrent complicated UTI, cystoscopy and imaging should be considered. CT urography or MR urography are usually appropriate for the evaluation of recurrent complicated lower urinary tract infections or for women who are nonresponders to conventional therapy, develop frequent reinfections or relapses, or have known underlying risk factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.09.003DOI Listing
November 2020

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

Mayo Clin Proc 2020 07 30;95(7):1467-1481. Epub 2020 May 30.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.

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.
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http://dx.doi.org/10.1016/j.mayocp.2020.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260518PMC
July 2020

Hemosiderin deposition in papillary renal cell carcinoma and its potential to mask enhancement on MRI: analysis of 110 cases.

Eur Radiol 2020 Nov 9;30(11):6033-6041. Epub 2020 Jun 9.

Department of Diagnostic Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.

Objectives: To evaluate the relationship between imperceptible T1 enhancement of papillary renal cell carcinoma (pRCC) on MR and intratumoral hemosiderin deposition.

Methods: One hundred ten pRCCs (≤ 7 cm) were evaluated by MR with in- and opposed-phase spoiled gradient echo (GRE) and T1-weighted spoiled GRE with fat suppression before and after contrast. Hemosiderin deposition was assessed by SI and D on in- and opposed-phase images. SI and D are calculated as (SI - SI)/(SI) × 100, where SI and SI are tumor signal intensities on in- and opposed-phase images and (D)/(D), where D and D are tumor diameters on in- and opposed-phase images, respectively. The degree of tumor enhancement was classified as grade 1 (no), grade 2 (subtle), or grade 3 (definite). Tumor enhancement on CT was assessed when available.

Results: Five (5%), 10 (9%), and 95 (86%) tumors were categorized as grades 1, 2, and 3 enhancement, respectively. The mean SI was - 33.9, - 25.3, and 1.00, whereas the mean D was 1.26, 1.05, and 1.00 in tumors with grades 1, 2, and 3 enhancement, respectively. Tumors with grade 1 enhancement had significantly lower SI (p = 0.001) and higher D (p = 0.005) than those with grade 3 enhancement. Among six tumors with grade 1 or 2 enhancement and available CT, four tumors showed > 20 HU enhancement.

Conclusions: pRCC with no subjective enhancement on contrast-enhanced MR showed hemosiderin deposition evident by lower SI and higher D. Hemosiderin deposition might mask the tumor enhancement on MR.

Key Points: • 5% of papillary renal cell carcinoma showed imperceptible enhancement on contrast-enhanced MR. • Hemosiderin deposition in papillary renal cell carcinoma might mask the tumor enhancement on contrast-enhanced MR due to T2/T2*-shortening effects. • A renal lesion with extensive hemosiderin deposition but no perceptible enhancement on MR should be considered suspicious for papillary renal cell carcinoma.
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http://dx.doi.org/10.1007/s00330-020-06994-4DOI Listing
November 2020

Modified acquisition strategy for reduced motion artifact in super resolution FSE multislice MRI: Application to prostate.

Magn Reson Med 2020 11 17;84(5):2537-2550. Epub 2020 May 17.

Biomedical Engineering and Physiology, Mayo Clinic, Rochester, MN, USA.

Purpose: To reduce slice-to-slice motion effects in multislice -weighted fast-spin-echo ( FSE) imaging, manifest as "scalloping" in reformats, by modification of the acquisition strategy and to show applicability in prostate MRI.

Methods: FSE images of contiguous or overlapping slices are typically acquired using multiple passes in which each pass is comprised of multiple slices with slice-to-slice gaps. Combination of slices from all passes provides the desired sampling. For enhancement of through-plane resolution with super resolution or for reformatting into other orientations, subtle ≈1 mm motion between passes can cause objectionable "scalloping" artifact. Here we address this by subdivision of each pass into multiple segments. Interleaving of segments from the multiple passes causes all slices to be acquired over substantially the same time, reducing pass-to-pass motion effects. This was implemented in acquiring 78 overlapped FSE axial slices and studied in phantoms and in 14 prostate MRI patients. Super-resolution axial images and sagittal reformats from the original and new segmented acquisitions were evaluated by 3 uroradiologists.

Results: For all criteria of sagittal reformats, the segmented acquisition was statistically superior to the original. For all sharpness criteria of axial images, although the trend preferred the original acquisition, the difference was not significant. For artifact in axial images, the segmented acquisition was significantly superior.

Conclusions: For prostate MRI the new segmented acquisition significantly reduces the scalloping motion artifact that can be present in reformats due to long time lags between the acquisition of adjacent or overlapped slices while retaining image sharpness in the acquired axial slices.
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http://dx.doi.org/10.1002/mrm.28315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402017PMC
November 2020

Variability of the Positive Predictive Value of PI-RADS for Prostate MRI across 26 Centers: Experience of the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel.

Radiology 2020 07 21;296(1):76-84. Epub 2020 Apr 21.

From the Departments of Radiology and Biomedical Imaging (A.C.W., R.J.Z.), Urology (A.C.W., P.R.C.), and Epidemiology and Biostatistics (C.E.M.) and the Clinical and Translational Science Institute (C.E.M.), University of California, San Francisco, 505 Parnassus Ave, M-392, Box 0628, San Francisco, CA 94143; Department of Diagnostic Imaging, Fox Chase Cancer Center, Philadelphia, Pa (J.M.A., R.B.P.); Departments of Radiology and Radiological Sciences (S.A., V.G.B) and Urologic Surgery (S.A.), Vanderbilt University Medical Center, Nashville, Tenn; Departments of Radiology (A.O.) and Urology (N.S.B), University of Chicago, Chicago, Ill; Departments of Radiology (J.O.B) and Nuclear Medicine (J.J.F.), Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands; Departments of Diagnostic Radiology (T.K.B., D.M.G), Interventional Radiology (S.E.M.), and Urology (J.F.W.), University of Texas MD Anderson Cancer Center, Houston, Tex; Diagnósticos da América S/A, Rio de Janeiro, Brazil (L.K.B); and Department of Radiology, Fluminense Federal University of Rio de Janeiro, Rio de Janeiro, Brazil (L.K.B.); Department of Radiology, University of California, San Diego, San Diego, Calif (M.T.B., M.E.H.); UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, Calif (P.R.C.); Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Ill (D.D.C., A.R.W.); Department of Radiology, University of British Columbia, Vancouver, Canada (S.D.C., R.D.); Department of Diagnostic Radiology, Oregon Health Science University, Portland, Ore (F.V.C., B.R.F.); Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, NM (S.C.E., B.S., J.B.S.); and Department of Radiology, Mayo Clinic, Rochester, Minn (A.T.F.). Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, Toronto, Canada (M.R.G., S.G.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (L.M.G.); Departments of Radiology (R.T.G.) and Surgery (R.T.G., T.J.P.), Duke University Medical Center and Duke Cancer Institute, Durham, NC; Department of Radiological Sciences and Urology, University of California, Irvine, Orange, Calif (R.H.); Virginia Commonwealth University School of Medicine, Richmond, Va (C.K.); Department of Radiology and Center for Imaging Sciences, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (C.K.K.); Department of Radiology, University of Florida College of Medicine, Jacksonville, Fla (C.L.); Department of Radiology, Weill Cornell Medicine, New York, NY (D.J.A.M.); Department of Radiology, University of Colorado at Denver, Denver, Colo (N.U.P.); Molecular Imaging Program (B.T.) and Urologic Oncology Branch (P.A.P.), National Cancer Institute, National Institutes of Health, Bethesda, Md; Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center, Houston, Tex (V.S.T.); Departments of Radiology (A.B.R.) and Urologic Oncology (S.S.T.), New York University Langone Health, New York, NY; Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio (S.V.); Department of Urology, University of Minnesota Institute for Prostate and Urologic Cancers, Minneapolis, Minn (C.A.W.); and Department of Radiology, Virginia Commonwealth University, Richmond, Va (J.Y.).

Background Prostate MRI is used widely in clinical care for guiding tissue sampling, active surveillance, and staging. The Prostate Imaging Reporting and Data System (PI-RADS) helps provide a standardized probabilistic approach for identifying clinically significant prostate cancer. Despite widespread use, the variability in performance of prostate MRI across practices remains unknown. Purpose To estimate the positive predictive value (PPV) of PI-RADS for the detection of high-grade prostate cancer across imaging centers. Materials and Methods This retrospective cross-sectional study was compliant with the HIPAA. Twenty-six centers with members in the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel submitted data from men with suspected or biopsy-proven untreated prostate cancer. MRI scans were obtained between January 2015 and April 2018. This was followed with targeted biopsy. Only men with at least one MRI lesion assigned a PI-RADS score of 2-5 were included. Outcome was prostate cancer with Gleason score (GS) greater than or equal to 3+4 (International Society of Urological Pathology grade group ≥2). A mixed-model logistic regression with institution and individuals as random effects was used to estimate overall PPVs. The variability of observed PPV of PI-RADS across imaging centers was described by using the median and interquartile range. Results The authors evaluated 3449 men (mean age, 65 years ± 8 [standard deviation]) with 5082 lesions. Biopsy results showed 1698 cancers with GS greater than or equal to 3+4 (International Society of Urological Pathology grade group ≥2) in 2082 men. Across all centers, the estimated PPV was 35% (95% confidence interval [CI]: 27%, 43%) for a PI-RADS score greater than or equal to 3 and 49% (95% CI: 40%, 58%) for a PI-RADS score greater than or equal to 4. The interquartile ranges of PPV at these same PI-RADS score thresholds were 27%-44% and 27%-48%, respectively. Conclusion The positive predictive value of the Prostate Imaging and Reporting Data System was low and varied widely across centers. © RSNA, 2020 See also the editorial by Milot in this issue.
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http://dx.doi.org/10.1148/radiol.2020190646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373346PMC
July 2020

Current Imaging Techniques for and Imaging Spectrum of Prostate Cancer Recurrence and Metastasis: A Pictorial Review.

Radiographics 2020 May-Jun;40(3):709-726. Epub 2020 Mar 20.

From the Department of Radiology (T.T., M.Y., A.K.) and Department of Hematology and Medical Oncology (A.H.B.), Mayo Clinic, Scottsdale, Ariz; Department of Radiology, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 700-8558, Japan (T.T., R.I., S.K.); and Department of Radiology, Mayo Clinic, Rochester, Minn (A.T.F.).

Relapsing level of prostate-specific antigen (PSA) after initial curative-intent local therapy for organ-confined prostate cancer is often the first sign of recurrence. However, PSA level recurrence does not enable accurate differentiation of locally recurrent tumor from metastatic disease or a combination of both. Metastatic prostate cancer most frequently involves bones and lymph nodes, followed by other organs such as the liver, lung, pleura, adrenal gland, ureter, peritoneum, penis, testis, and meninges. Conventional imaging including CT and bone scintigraphy has long been the standard of care but has limited sensitivity in depicting early local recurrence or metastatic disease. Multiparametric MRI has been shown to be more sensitive in detecting locally recurrent tumor in the prostatectomy bed as well as in situ recurrence in a prostate gland that has been treated with radiation therapy or thermal ablation. In addition, lesions detected with multiparametric MRI may be amenable to targeted biopsy for definitive diagnosis of recurrence. PET/CT or PET/MRI using the U.S. Food and Drug Administration (FDA)-approved tracers carbon 11 choline or fluorine 18 fluciclovine has demonstrated markedly increased sensitivity and specificity for diagnosis of early metastatic disease such as small-volume lymph node metastasis, as have a range of investigational gallium 68 prostate-specific membrane antigen (PSMA) radioactive PET tracers. With recent advances in imaging modalities and techniques, more accurate early detection, localization, and characterization of recurrent prostate cancer have become possible. The authors present a contemporary review of the strengths and limitations of conventional and advanced imaging modalities in evaluation of patients with recurrent prostate cancer and a systematic review of the clinical and imaging features of locally recurrent and metastatic disease.RSNA, 2020See discussion on this article by Barwick and Castellucci.
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http://dx.doi.org/10.1148/rg.2020190121DOI Listing
April 2021

Post-treatment prostate MRI.

Abdom Radiol (NY) 2020 07;45(7):2184-2197

Department of Radiology, Duke University Medical Center, DUMC Box 3808, Durham, NC, 27710, USA.

Accurate early detection of recurrent prostate cancer after surgical or nonsurgical treatment is increasingly relevant in the era of evolving options for salvage therapy. The importance of differentiating between local tumor recurrence, distant metastatic disease, and a combination of both in a patient with biochemical recurrence of prostate cancer is essential for appropriate treatment selection. Magnetic resonance imaging (MRI) is the best test for localization and characterization of locally residual or recurrent prostate cancer. It is essential for the radiologist involved in prostate MRI interpretation to be familiar with key imaging findings and advantages of different sequences to reach a confident diagnosis in the post-treatment setting. In this pictorial review, we present imaging findings of post-treatment prostate MRI including expected post-treatment anatomy and imaging characteristics, and the typical appearances of local tumor recurrence after radical prostatectomy, radiation therapy, and focal therapy for prostate cancer. While a multi-parametric MRI approach remains key just as in the treatment-naïve gland, this review emphasizes the much greater importance of the dynamic contrast-enhanced MRI sequence for evaluation in the post-treatment setting.
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http://dx.doi.org/10.1007/s00261-019-02348-xDOI Listing
July 2020

ACR Appropriateness Criteria® Post-Treatment Surveillance of Bladder Cancer.

J Am Coll Radiol 2019 Nov;16(11S):S417-S427

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

Urothelial cancer is the second most common cancer, and cause of cancer death, related to the genitourinary tract. The goals of surveillance imaging after the treatment of urothelial cancer of the urinary bladder are to detect new or previously undetected urothelial tumors, to identify metastatic disease, and to evaluate for complications of therapy. For surveillance, patients can be stratified into one of three groups: (1) nonmuscle invasive bladder cancer with no symptoms or additional risk factors; (2) nonmuscle invasive bladder cancer with symptoms or additional risk factors; and (3) muscle invasive bladder cancer. This article is a review of the current literature for urothelial cancer and resulting recommendations for surveillance imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.05.026DOI Listing
November 2019

ACR Appropriateness Criteria® Penetrating Trauma-Lower Abdomen and Pelvis.

J Am Coll Radiol 2019 Nov;16(11S):S392-S398

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

Lower urinary tract injury is most commonly the result of blunt trauma but can also result from penetrating or iatrogenic trauma. Clinical findings in patients with a mechanism of penetrating trauma to the lower urinary tract include lacerations or puncture wounds of the pelvis, perineum, buttocks, or genitalia, as well as gross hematuria or inability to void. CT cystography or fluoroscopy retrograde cystography are usually the most appropriate initial imaging procedures in patients with a mechanism of penetrating trauma to the lower urinary tract. CT of the pelvis with intravenous contrast, pelvic radiography, fluoroscopic retrograde urethrography, and CT of the pelvis without intravenous contrast may be appropriate in some cases. Arteriography, radiographic intravenous urography, CT of the pelvis without and with intravenous contrast, ultrasound, MRI, and nuclear scintigraphy are usually not appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.05.023DOI Listing
November 2019

ACR Appropriateness Criteria® Lower Urinary Tract Symptoms-Suspicion of Benign Prostatic Hyperplasia.

J Am Coll Radiol 2019 Nov;16(11S):S378-S383

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

Lower urinary tract symptoms due to benign prostatic enlargement have a high prevalence in men over 50 years of age. Diagnosis is made with a combination of focused history and physician examination and validated symptom questionnaires. Urodynamic studies can help to differentiate storage from voiding abnormalities. Pelvic ultrasound may be indicated to assess bladder volume and wall thickness. Other imaging modalities, including prostate MRI, are usually not indicated in the initial workup and evaluation of uncomplicated lower urinary tract symptoms from an enlarged prostate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.05.031DOI Listing
November 2019

Prostatic Remnant After Prostatectomy: MR Findings and Prevalence in Clinical Practice.

AJR Am J Roentgenol 2020 01 31;214(1):W37-W43. Epub 2019 Oct 31.

Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

The purpose of this article is to evaluate the MR findings of prostatic remnant after prostatectomy and estimate the prevalence of prostatic remnant in patients that undergo MRI after prostatectomy. Sixty-six patients who had undergone radical prostatectomy with pathologically proven benign prostatic remnant between 2007 and 2017 were retrospectively reviewed. Pathologically proven benign prostatic remnant was determined on the basis of initial pathologic report. Of the 66 initial patients, 30 patients with biopsy-proven benign prostatic remnant without coexisting recurrent prostate carcinoma and three patients who underwent repeat resection for completion prostatectomy were enrolled. MRI characteristics including location, size, signal intensity on T2-weighted images and DWI, and contrast enhancement pattern were analyzed. Nine additional patients were found to have a prostatic remnant by imaging without biopsy. The prevalence of prostatic remnant among those undergoing MRI for suspected recurrence during the same period was estimated. Prostatic remnant was detected in 23 of 33 patients on MRI. The remaining 10 patients did not have any visible abnormality. The 23 detected lesions were located in three regions: under the vesicourethral anastomosis in five patients, in the bladder neck in 12 patients, and posterior to the bladder in six patients. On T2-weighted imaging, 17 of 23 lesions showed heterogeneous hyperintensity. On DWI, 14 lesions showed hyperintensity. Dedicated MRI studies were performed for suspected prostate cancer recurrence in 2466 patients during the same period. Prevalence of exclusively benign prostate remnant detectable on MRI was approximately 1% of that population (23/2466-35/2466), and overall prevalence of any prostate remnant detectable on MRI was 3% (75/2466). Benign prostate remnant after prostatectomy occurs at three common sites and typically shows heterogeneous hyperintensity on T2-weighted imaging. The prevalence of detectable prostatic remnant in men who undergo MRI for suspected recurrence was approximately 1-3%.
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http://dx.doi.org/10.2214/AJR.19.21345DOI Listing
January 2020

Mesenteric ischemia: what the radiologist needs to know.

Cardiovasc Diagn Ther 2019 Aug;9(Suppl 1):S74-S87

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

Acute mesenteric ischemia (AMI) is a life-threatening condition that often presents with abdominal pain. Early diagnosis with contrast-enhanced computed tomography and revascularization can reduce the overall mortality in AMI. This article reviews practical etiological classification, pathophysiology of imaging manifestations and common pitfalls in intestinal ischemia.
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http://dx.doi.org/10.21037/cdt.2018.09.06DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732105PMC
August 2019

ACR Appropriateness Criteria Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass.

J Am Coll Radiol 2019 May;16(5S):S38-S43

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

An acute scrotum is defined as testicular swelling with acute pain and can reflect multiple etiologies including epididymitis or epididymo-orchitis, torsion of the spermatic cord, or torsion of the testicular appendages. Quick and accurate diagnosis of acute scrotum and its etiology with imaging is necessary because a delayed diagnosis of torsion for as little as 6 hours can cause irreparable testicular damage. Ultrasound duplex Doppler of the scrotum is usually appropriate as the initial imaging for the acute onset of scrotal pain without trauma or antecedent mass in an adult or child. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.02.016DOI Listing
May 2019

Use of k -space for high through-plane resolution in multislice MRI: Application to prostate.

Magn Reson Med 2019 06 7;81(6):3691-3704. Epub 2019 Mar 7.

Biomedical Engineering and Physiology, Mayo Clinic, Rochester, Minnesota.

Purpose: The goal of this work is to demonstrate 1 mm through-plane resolution in multislice T2SE MRI using k -space processing of overlapping slices and show applicability in prostate MRI.

Methods: Multiple overlapped slices are acquired and Fourier transformed in the slice-select direction. The slice profile is incorporated into a Tikhonov-regularized reconstruction. Through-plane resolution is tested in a resolution phantom. An anthropomorphic prostate phantom is used to study the SNR, and results are compared with theoretical prediction. The proposed method is tested in 16 patients indicated for clinical prostate MRI who gave written informed consent as overseen by our IRB. The "proposed" vs. "reference" multislice images are compared using multiple evaluation criteria for through-plane resolution.

Results: The modulation transfer function (MTF) plots of the resolution phantom show good modulation at frequency 0.5 lp/mm, demonstrating 1 mm through-plane resolution restoration. The SNR measurements experimentally match the theoretically predicted values. The radiological evaluation shows that the proposed method is superior to the reference method for five criteria of sharpness but inferior with respect to artifacts.

Conclusions: In conjunction with overlapped slices a k -space-based reconstruction approach can be used to improve through-plane resolution in multislice T2SE MRI. 1 mm resolution is demonstrated from 3.2 mm thick slices. The in vivo results from prostate MRI show improved sharpness when compared to the standard multislice method.
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http://dx.doi.org/10.1002/mrm.27691DOI Listing
June 2019

Safety and Image Quality of 1.5-T Endorectal Coil Multiparametric MRI of the Prostate or Prostatectomy Fossa for Patients With Pacemaker or Implantable Cardioverter-Defibrillator.

AJR Am J Roentgenol 2019 04 30;212(4):815-822. Epub 2019 Jan 30.

3 Department of Radiology, Mayo Clinic, Rochester, MN.

Objective: The purpose of this study is to report the patient safety and image quality of 1.5-T multiparametric MRI of the prostate in patients with cardiac implantable electronic devices (CIEDs).

Materials And Methods: In this retrospective study, a database was searched to identify prostate multiparametric 1.5-T MRI examinations performed with endorectal coils for patients with CIEDs from 2012 to 2016 (study group) and matched patients without CIEDs (control group). Clinical safety in the study group was reviewed. The specific absorption rate (SAR) and signal-to-noise ratio (SNR) were measured in both groups. Imaging quality and artifact on T2-weighted images, DW images, and dynamic contrast-enhanced images were rated on a 5-point scale by two independent readers.

Results: The study group consisted of total 28 multiparametric MRI examinations in 25 patients. There were no serious device-related adverse effects observed (0/28; 0%), and the estimated whole-body SAR in the study group was never greater than 1.5 W/kg. The SNR values tended to be lower in the study group than in the control group. However, overall perceived image preferences and influences of artifacts on image quality for the study group were not significantly different from those for the control group (p > 0.05), which were rated above average (rating 3) by both readers 1 and 2.

Conclusion: Multiparametric 1.5-T MRI examination of the prostate can be safely performed in selected patients with CIEDs under controlled conditions with applicable image quality while maintaining a SAR less than 1.5 W/kg.
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http://dx.doi.org/10.2214/AJR.18.20266DOI Listing
April 2019

High-pitch versus standard mode CT pulmonary angiography: a comparison of indeterminate studies.

Emerg Radiol 2019 Apr 13;26(2):155-159. Epub 2018 Nov 13.

Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.

Purpose: To compare the causes of indeterminate CT pulmonary angiograms using standard mode and high-pitch mode, and determine at what level of the pulmonary arterial tree studies were non-diagnostic.

Methods: IRB approval was obtained. A retrospective review of patients at our institution who underwent a CT pulmonary angiogram, between November 1, 2015 and February 10, 2016 was performed. CT pulmonary angiograms using both high-pitch mode and standard mode were evaluated with positive and indeterminate rates calculated. Causes of indeterminate studies and the level of the pulmonary arterial tree at which the study became non-diagnostic were determined by a board certified radiologist by looking at the images of each indeterminate study. The indeterminate rates were compared between high-pitch and standard modes using a generalized estimating equation.

Results: Five hundred fifty-nine CT pulmonary angiograms using high-pitch mode were evaluated, while 661 standard mode scans were evaluated. 69/559 (12.3%) scans with high-pitch mode were positive and 84/661 (12.7%) scans with standard mode were positive (not statistically significant, p > 0.05). There was a higher rate of indeterminate scans with standard mode compared to the high-pitch mode (80 [12.1%] standard vs. 25 [4.5%] high-pitch, p value < 0.0001). Findings were indeterminate at the lobar level in 4 (16%), at the segmental level in 11 (44%), and at the subsegmental level in 10 (40%) using high-pitch mode. The most common causes of an indeterminate scan using high-pitch mode were motion in 11 (44%), transient interruption of contrast in 6 (24%), and contrast timing in 5 (20%). Findings were indeterminate at the main pulmonary artery level in 1 (1.3%), at the lobar level in 13 (16.3%), at the segmental level in 28 (35.0%), and at the subsegmental level in 38 (47.5%) using the standard mode. The most common causes of an indeterminate scan using the standard mode were motion in 53 (66.3%), transient interruption of contrast in 19 (23.8%), and contrast timing in 15 (18.8%).

Conclusions: High-pitch mode results in statistically significant fewer indeterminate studies compared with standard mode. Furthermore, there were statistically significant fewer indeterminate studies due to motion artifact with high-pitch mode compared with standard mode.
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http://dx.doi.org/10.1007/s10140-018-1656-1DOI Listing
April 2019

CT for Evaluation of Acute Gastrointestinal Bleeding.

Radiographics 2018 Jul-Aug;38(4):1089-1107. Epub 2018 Jun 8.

From the Departments of Radiology (M.L.W., J.G.F., A.T.F., J.M.B., J.L.F.) and Gastroenterology (S.L.H., D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905.

Acute gastrointestinal (GI) bleeding is common and necessitates rapid diagnosis and treatment. Bleeding can occur anywhere throughout the GI tract and may be caused by many types of disease. The variety of enteric diseases that cause bleeding and the tendency for bleeding to be intermittent may make it difficult to render a diagnosis. The workup of GI bleeding is frequently prolonged and expensive, with examinations commonly needing to be repeated. The use of computed tomography (CT) for evaluation of acute GI bleeding is gaining popularity because it can be used to rapidly diagnose active bleeding and nonbleeding bowel disease. The CT examinations used to evaluate acute GI bleeding include CT angiography and multiphase CT enterography. Understanding the clinical evaluation of acute GI bleeding, including the advantages and limitations of endoscopic evaluation, is necessary for the appropriate selection of patients who may benefit from CT. Multiphase CT enterography is used primarily to evaluate stable patients who have undergone upper and lower endoscopy without identification of a bleeding source. CT angiography is used to examine stable and unstable patients who respond to resuscitation, are believed to be actively bleeding, and are considered unlikely to have an upper GI source of hemorrhage. In the emergent setting, CT may yield critical information regarding the presence, location, and cause of active bleeding-data that can guide the choice of subsequent therapy. Recent developments in the use of and techniques for performing CT angiography have made it a potential first-line tool for evaluating acute GI bleeding. RSNA, 2018.
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http://dx.doi.org/10.1148/rg.2018170138DOI Listing
October 2018

ACR Appropriateness Criteria Pretreatment Staging of Muscle-Invasive Bladder Cancer.

J Am Coll Radiol 2018 May;15(5S):S150-S159

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

Muscle-invasive bladder cancer (MIBC) has a tendency toward urothelial multifocality and is at risk for local and distant spread, most commonly to the lymph nodes, bone, lung, liver, and peritoneum. Pretreatment staging of MIBC should include imaging of the urothelial upper tract for synchronous lesions; imaging of the chest, abdomen, and pelvis for metastases; and MRI pelvis for local staging. CT abdomen and pelvis without and with contrast (CT urogram) is recommended to assess the urothelium and abdominopelvic organs. Pelvic MRI can improve local bladder staging accuracy. Chest imaging is also recommended with chest radiograph usually being adequate. FDG-PET/CT may be appropriate to identify nodal and metastatic disease. Chest CT may be useful in high-risk patients and those with findings on chest radiograph. Nonurogram CT and MRI of the abdomen and pelvis are usually not appropriate, and neither is radiographic intravenous urography, Tc-99m whole body bone scan, nor bladder ultrasound for pretreatment staging of MIBC. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.03.020DOI Listing
May 2018

ACR Appropriateness Criteria Post-treatment Follow-up Prostate Cancer.

J Am Coll Radiol 2018 May;15(5S):S132-S149

Specialty Chair, Cleveland Clinic, Cleveland, Ohio.

Diagnosis and management of prostate cancer post treatment is a large and complex problem, and care of these patients requires multidisciplinary involvement of imaging, medical, and surgical specialties. Imaging capabilities for evaluation of men with recurrent prostate cancer are rapidly evolving, particularly with PET and MRI. At the same time, treatment options and capabilities are expanding and improving. These recommendations separate patients into three broad categories: (1) patients status post-radical prostatectomy, (2) clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments, and (3) metastatic prostate. This article is a review of the current literature regarding imaging in these settings and the resulting recommendations for imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.03.019DOI Listing
May 2018

Robust and efficient pharmacokinetic parameter non-linear least squares estimation for dynamic contrast enhanced MRI of the prostate.

Magn Reson Imaging 2018 05 24;48:50-61. Epub 2017 Dec 24.

Biomedical Engineering and Physiology Program, Mayo Graduate School, Rochester, MN, United States; Department of Radiology, Mayo Clinic, Rochester, MN, United States. Electronic address:

Purpose: To describe an efficient numerical optimization technique using non-linear least squares to estimate perfusion parameters for the Tofts and extended Tofts models from dynamic contrast enhanced (DCE) MRI data and apply the technique to prostate cancer.

Methods: Parameters were estimated by fitting the two Tofts-based perfusion models to the acquired data via non-linear least squares. We apply Variable Projection (VP) to convert the fitting problem from a multi-dimensional to a one-dimensional line search to improve computational efficiency and robustness. Using simulation and DCE-MRI studies in twenty patients with suspected prostate cancer, the VP-based solver was compared against the traditional Levenberg-Marquardt (LM) strategy for accuracy, noise amplification, robustness to converge, and computation time.

Results: The simulation demonstrated that VP and LM were both accurate in that the medians closely matched assumed values across typical signal to noise ratio (SNR) levels for both Tofts models. VP and LM showed similar noise sensitivity. Studies using the patient data showed that the VP method reliably converged and matched results from LM with approximate 3× and 2× reductions in computation time for the standard (two-parameter) and extended (three-parameter) Tofts models. While LM failed to converge in 14% of the patient data, VP converged in the ideal 100%.

Conclusion: The VP-based method for non-linear least squares estimation of perfusion parameters for prostate MRI is equivalent in accuracy and robustness to noise, while being more reliably (100%) convergent and computationally about 3× (TM) and 2× (ETM) faster than the LM-based method.
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http://dx.doi.org/10.1016/j.mri.2017.12.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889971PMC
May 2018

Multiparametric Magnetic Resonance Imaging Is an Independent Predictor of Salvage Radiotherapy Outcomes After Radical Prostatectomy.

Eur Urol 2018 06 28;73(6):879-887. Epub 2017 Nov 28.

Department of Urology, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: The Stephenson nomogram is widely used to estimate the success of salvage radiotherapy (sXRT) for prostate cancer (PCa) recurrence after radical prostatectomy (RP).

Objective: To determine whether multiparametric pelvic magnetic resonance imaging (mpMRI) performed for biochemical recurrence after RP improves prognostication of sXRT relative to the Stephenson nomogram.

Design, Setting, And Participants: Men undergoing RP at our institution from 2003 to 2012 who had biochemical recurrence evaluated by mpMRI within 12 mo of sXRT were retrospectively reviewed. Exclusion criteria included PCa treatment prior to RP, adjuvant XRT after RP, salvage cryotherapy before sXRT, and hormone refractory disease prior to sXRT.

Outcome Measurements And Statistical Analysis: Multivariable Cox regression analyses (adjusting for Stephenson nomogram covariates) associated mpMRI findings with prostate-specific antigen (PSA) recurrence and metastasis after sXRT. The mpMR images were compared in a binary fashion: no lesion versus vesicourethral/seminal vesical bed/prostate fossa lesions.

Results And Limitations: Among 473 sXRT patients, 57%(204) had lesions on mpMRI: 26%(124) vesicourethral, 28%(135) seminal vesical bed/prostatic fossa, 7%(34) nodal, and 1%(3) bone. Median PSA at mpMRI with lesions was 0.46 versus 0.40ng/ml without lesions. After excluding nodal/bone lesions, 29% of men developed PSA recurrence and 14% metastasis (median follow-up 45 mo after sXRT). For patients with a pre-sXRT PSA of ≤0.5ng/ml, negative mpMRI was associated with increased PSA recurrence (39% vs 12%, p<0.01) and metastasis (16% vs 2%, p<0.01) at 4 yr after sXRT. For patients with a PSA of ≤0.5ng/ml, the addition of mpMRI to the propensity score (created using variables from the original Stephenson nomogram) improved the c-statistic from 0.71 to 0.77 for PSA recurrence (hazard ratio [HR] 3.60, p<0.01) and from 0.66 to 0.77 for metastasis (HR 6.68, p<0.01). Limitations include evolutions in MRI technique and lack of a cohort of men undergoing mpMRI electing against sXRT.

Conclusions: Pre-sXRT mpMRI improves clinicopathologic variables to estimate sXRT success, particularly in the early sXRT setting.

Patient Summary: Men who have biochemically recurrent prostate cancer after radical prostatectomy often receive salvage radiotherapy. In our study, multiparametric pelvic magnetic resonance imaging prior to salvage radiotherapy was a significant predictor of prostate-specific antigen failure and metastasis after radiotherapy.
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http://dx.doi.org/10.1016/j.eururo.2017.11.012DOI Listing
June 2018

Conventional vs. reduced field of view diffusion weighted imaging of the prostate: Comparison of image quality, correlation with histology, and inter-reader agreement.

Magn Reson Imaging 2018 04 5;47:67-76. Epub 2017 Dec 5.

Department of Radiology, Mayo Clinic, Rochester, MN, United States. Electronic address:

Purpose: To evaluate if Field of view Optimized and Constrained Undistorted Single shot (FOCUS) (GE Healthcare, Waukesha, WI) diffusion weighted images (DWI) provide more reliable imaging than conventional DWI, with non-inferior quantitative apparent diffusion coefficient (ADC) results.

Material And Methods: IRB approval was obtained for this study of 43 patients (44 exams, one patient with two visits) that underwent multiparametric prostate MRI with two DWI sequences and subsequent radical prostatectomy with histology as the gold standard. Randomized DWI sequence images were graded independently by two blinded experienced prostate MRI radiologists with a period of memory extinction between the two separate reading sessions. Blinded images were also reviewed head to head in a later session for direct comparison. Multiple parameters were measured from a region of interest in a dominant lesion as well as two control areas. Patient characteristics were collected by chart review.

Results: There was good correlation between the mean ADC value for lesions obtained by conventional and FOCUS DWI (ρ=0.85), with no trend toward any systematic difference, and equivalent correlation between ADC measurements and Gleason score. Agreement between the two readers was significantly higher for lesion ROI analysis with the FOCUS DWI derived ADC values (CCC 0.839) compared with the conventional ADC values (CCC 0.618; difference 0.221, 95% CI 0.01-0.46). FOCUS showed significantly better image quality scores (separate review: mean 2.17±0.6, p<0.001) compared to the conventional sequence (mean 2.65±0.6, p<0.001). In 13 cases the image quality was improved from grade of 3+ with conventional DWI to <3 with FOCUS DWI, a clinically meaningful improvement. Head-to-head blinded review found 61 ratings showed strong to slight preference for FOCUS, 13 no preference, and 14 slight preference for the conventional sequence. There was also a strong and equivalent correlation between both sequences and PIRADS version 2 grading (ρ=-0.56 and -0.58 for FOCUS and conventional, respectively, p<0.001 for both).

Conclusion: FOCUS DWI of the prostate shows significant improvement in inter-reader agreement and image quality. As opposed to previous conflicting smaller studies, we found equivalent ADC metrics compared with the conventional DWI sequence, and preserved correlation with Gleason score. In 52% of patients the improved image quality with FOCUS had the potential to salvage exams with otherwise limited to non-diagnostic DWI.
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http://dx.doi.org/10.1016/j.mri.2017.10.011DOI Listing
April 2018

ACR Appropriateness Criteria Prostate Cancer-Pretreatment Detection, Surveillance, and Staging.

J Am Coll Radiol 2017 May;14(5S):S245-S257

Panel Chair, University of New Mexico, Albuquerque, New Mexico.

Despite the frequent statement that "most men die with prostate cancer, not of it," the reality is that prostate cancer is second only to lung cancer as a cause of death from malignancy in American men. The primary goal during baseline evaluation of prostate cancer is disease characterization, that is, establishing disease presence, extent (local and distant), and aggressiveness. Prostate cancer is usually diagnosed after the finding of a suspicious serum prostate-specific antigen level or digital rectal examination. Tissue diagnosis may be obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy. The latter requires a preliminary multiparametric MRI, which has emerged as a powerful and relatively accurate tool for the local evaluation of prostate cancer over the last few decades. Bone scintigraphy and CT are primarily used to detect bone and nodal metastases in patients found to have intermediate- or high-risk disease at biopsy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2017.02.026DOI Listing
May 2017

Improved performance of prostate DCE-MRI using a 32-coil vs. 12-coil receiver array.

Magn Reson Imaging 2017 06 27;39:15-23. Epub 2017 Jan 27.

Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States. Electronic address:

Purpose: To assess whether acquisition with 32 receiver coils rather than the vendor-recommended 12 coils provides significantly improved performance in 3D dynamic contrast-enhanced MRI (DCE-MRI) of the prostate.

Materials: The study was approved by the institutional review board and was compliant with HIPAA. 50 consecutive male patients in whom prostate MRI was clinically indicated were prospectively imaged in March 2015 with an accelerated DCE-MRI sequence in which image reconstruction was performed using 12 and 32 coil elements. The two reconstructions were compared quantitatively and qualitatively. The first was done using signal-to-noise ratio (SNR) and g-factor analysis to assess sensitivity to acceleration. The second was done using a five-point scale by two experienced radiologists using criteria of perceived SNR, artifact, sharpness, and overall preference. Significance was assessed with the Wilcoxon signed rank test. Extension to T2-weighted spin-echo and diffusion sequences was assessed in phantom studies.

Results: Reconstruction using 32 vs. 12 coil elements provided improved performance in DCE-MRI based on intrinsic SNR (18% higher) and g-factor statistics (14% higher), with a median 32% higher overall SNR within the prostate volume over all subjects. Reconstruction using 32 coils was qualitatively rated significantly improved (p<0.001) vs. 12 coils on the basis of perceived SNR and radiologist preference and equivalent for sharpness and artifact. Phantom studies suggested the improvement in intrinsic SNR could extend to T2-weighted spin-echo and diffusion sequences.

Conclusions: Reconstruction of 3D accelerated DCE-MRI studies of the prostate using 32 independent receiver coils provides improved overall performance vs. using 12 coils.
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http://dx.doi.org/10.1016/j.mri.2017.01.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5410393PMC
June 2017

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

Eur Urol 2017 05 28;71(5):701-704. Epub 2016 Aug 28.

Department of Urology, Mayo Clinic in Rochester, MN, USA. Electronic address:

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.

Patient Summary: Magnetic resonance imaging, together with clinical information, can be useful in preoperative assessment before radical prostatectomy.
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http://dx.doi.org/10.1016/j.eururo.2016.08.015DOI Listing
May 2017
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