Publications by authors named "Antonio C Westphalen"

120 Publications

The impact and collateral damage of COVID-19 on prostate MRI and guided biopsy operations: Society of Abdominal Radiology Prostate Cancer Disease-Focused Panel survey analysis.

Abdom Radiol (NY) 2021 Apr 27. Epub 2021 Apr 27.

Department Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.

The Coronavirus disease 2019 (COVID-19) pandemic has significantly affected health care systems throughout the world. A Qualtrics survey was targeted for radiologists around the world to study its effect on the operations of prostate MRI studies and biopsies. Descriptive statistics were reported. A total of 60 complete responses from five continents were included in the analysis. 70% of the responses were from academic institutions. Among all participants, the median (range) number of prostate MRI was 20 (0, 135) per week before the COVID-19 pandemic versus 10 (0, 30) during the lockdown period; the median (range) number of prostate biopsies was 4.5 (0, 60) per week before the COVID-19 versus 0 (0, 12) during the lockdown period. Among the 30% who used bowel preparation for their patients prior to MRI routinely, 11% stopped the bowel preparation due to the pandemic. 47% reported that their radiology departments faced staff disruptions, while 68% reported changes in clinic schedules in other clinical departments, particularly urology, genitourinary medical oncology, and radiation oncology. Finally, COVID-19 pandemic was found to disrupt not only the clinical prostate MRI operations but also impacted prostate MRI/biopsy research in up to 50% of institutions. The impact of this collateral damage in delaying diagnosis and treatment of prostate cancer is yet to be explored.
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http://dx.doi.org/10.1007/s00261-021-03087-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077193PMC
April 2021

Diagnostic Accuracy and Prognostic Value of Serial Prostate Multiparametric Magnetic Resonance Imaging in Men on Active Surveillance for Prostate Cancer.

Eur Urol Oncol 2021 Jan 19. Epub 2021 Jan 19.

Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA.

Background: Multiparametric magnetic resonance imaging (MRI) is increasingly utilized to improve the detection of clinically significant prostate cancer. Evidence for serial MRI in men on active surveillance (AS) is lacking.

Objective: To evaluate the role of MRI in detecting Gleason grade group (GG) ≥2 disease in confirmatory and subsequent surveillance biopsies for men on AS.

Design, Setting, And Participants: This was a single-center study of men with low-risk prostate cancer enrolled in an AS cohort between 2006 and 2018. All men were diagnosed by systematic biopsy and underwent MRI prior to confirmatory ("MRI1") and subsequent surveillance ("MRI2") biopsies. MRI lesions were scored with Prostate Imaging Reporting and Data System (PI-RADS) version 2.

Outcome Measurements And Statistical Analysis: The primary outcome was biopsy upgrade to GG ≥ 2 prostate cancer, and the secondary outcome was definitive treatment. Test characteristics for PI-RADS score were calculated. Multivariable logistic and Cox proportional hazard regression models were used to determine the associations between PI-RADS score change and outcomes, on a per-examination basis.

Results And Limitations: Of 125 men with a median follow-up of 78 mo, 38% experienced an increase in PI-RADS scores. The sensitivity and positive predictive value of PI-RADS ≥3 for GG ≥ 2 disease improved from MRI1 to MRI2 (from 85% to 91% and from 26% to 49%, respectively). An increase in PI-RADS scores from MRI1 to MRI2 was associated with GG ≥ 2 (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.7-13.2) compared with PI-RADS 1-3 on both MRI scans. Men with PI-RADS 4-5 lesions on both MRI scans had a higher likelihood of GG ≥ 2 than patients with PI-RADS 1-3 lesions on both (OR 3.3, 95% CI 1.3-8.6). Importantly, any increase in PI-RADS scores was independently associated with definitive treatment (hazard ratio 3.9, 95% CI 1.3-11.9). This study was limited by its retrospective, single-center design.

Conclusions: The prognostic value of MRI improves with serial examination and provides additional risk stratification. Validation in other cohorts is needed.

Patient Summary: We looked at the role of serial prostate magnetic resonance imaging in men with low-risk prostate cancer on active surveillance at the University of California, San Francisco. We found that both consistently visible and increasingly suspicious lesions were associated with biopsy upgrade and definitive treatment.
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http://dx.doi.org/10.1016/j.euo.2020.11.007DOI Listing
January 2021

Gastrointestinal Stromal Tumor Incidentally Detected on 18F-Fluciclovine PET/CT.

Clin Nucl Med 2021 Apr;46(4):345-347

Division of Abdominal Imaging, Department of Radiology, University of Washington, Seattle, WA.

Abstract: We present a case of metastatic gastrointestinal stromal tumor incidentally detected on 18F-fluciclovine PET/CT. A 68-year-old man with history of intermediate-risk prostate cancer (Gleason score 4 + 3 = 7; pT2cN0M0) previously treated with retropubic radical prostatectomy, adjuvant whole pelvis radiation, and androgen deprivation therapy (leuprolide) presented with slowly rising serum prostate-specific antigen over 3 years, concerning for recurrent prostate cancer. To identify potential sites of recurrent disease, an 18F-fluciclovine PET/CT was obtained. Multiple tracer-avid mesenteric masses and enlarged lymph nodes were found throughout the abdomen and pelvis, later biopsy-proven to reflect metastatic gastrointestinal stromal tumor.
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http://dx.doi.org/10.1097/RLU.0000000000003426DOI Listing
April 2021

SAR Prostate Cancer Disease-Focused Panel report.

Abdom Radiol (NY) 2020 12 23;45(12):3948-3950. Epub 2020 Nov 23.

Department of Radiology and Radiation Oncology, University of Washington, 1959 NE Pacific St, BB308, Seattle, WA, 98195, USA.

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http://dx.doi.org/10.1007/s00261-020-02862-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682688PMC
December 2020

Introduction to the special issue: Prostate Cancer Update.

Abdom Radiol (NY) 2020 12 21;45(12):3947. Epub 2020 Nov 21.

Department of Radiology and Radiation Oncology, University of Washington, 1959 NE Pacific St, Seattle, WA, BB308, USA.

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http://dx.doi.org/10.1007/s00261-020-02861-4DOI Listing
December 2020

How Often Does Magnetic Resonance Imaging Detect Prostate Cancer Missed by Transrectal Ultrasound?

Eur Urol Focus 2020 Aug 28. Epub 2020 Aug 28.

Department of Urology, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA. Electronic address:

Background: Lesion-targeted prostate biopsy based on multiparametric magnetic resonance imaging (mpMRI) has been shown to be superior to systematic transrectal ultrasound (TRUS) biopsy (SBx) alone in men at risk for prostate cancer (PCa). However, the incremental benefit of MRI-targeted biopsy (MBx) beyond SBx with ultrasound-targeted biopsy (UBx) is less clear.

Objective: We performed a three-way comparison of UBx versus MBx versus SBx for PCa detection.

Design, Setting, And Participants: A prospective, single-center cohort study was conducted on consecutive patients with PCa suspicion or low-risk PCa on active surveillance (AS). All men had at least one lesion (Prostate Imaging Reporting and Data System [PI-RADS] ≥3) on pre-biopsy mpMRI. UBx, MBx, and SBx were performed during the same encounter, and the urologists were blinded to MRI results and targeting until both SBx and UBx were completed.

Outcome Measurements And Statistical Analysis: The ability of each biopsy type to identify the highest grade group (GG) was determined, and UBx and MBx were compared using a paired t test.

Results And Limitations: We prospectively enrolled 201 consecutive men undergoing targeted prostate biopsy: 72 (36%) were biopsy-naïve, 34 (17%) had a prior negative SBx, and 95 (47%) were on AS. Median age and prostate-specific antigen were 66 yr (interquartile range [IQR] 62-71) and 6.8 ng/ml (IQR 4.9-9.8), respectively. Suspicious hypoechoic lesions were reported on TRUS in 69%. Among the 169 men with PCa, SBx detected the highest GG or was equivalent to UBx/MBx in 136 (80%) men. UBx detected the highest GG or was equivalent to MBx in 19 (11%) men, and MBx alone detected the highest GG in 14 (8%) men. There was no significant difference between UBx and MBx in direct comparison (p = 0.08). Limitations include that patients were not randomized, our population was heterogeneous, and TRUS expertise at a tertiary care academic center might not reflect routine practice.

Conclusions: In the setting of high expertise and experience with both ultrasound and MRI, MBx offers only a modest benefit over SBx and UBx.

Patient Summary: At a highly experienced academic medical center, we examined the detection rates of prostate cancer among men undergoing prostate biopsy using three techniques: transrectal ultrasound lesion-targeted biopsy, magnetic resonance imaging-targeted biopsy, and systematic biopsy. We identified a few more cases of aggressive prostate cancer with magnetic resonance imaging-targeted biopsy, but a large majority was found by ultrasound alone.
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http://dx.doi.org/10.1016/j.euf.2020.08.003DOI Listing
August 2020

PET-detected asymptomatic recurrence is associated with improved survival in recurrent cervical cancer.

Abdom Radiol (NY) 2021 01 8;46(1):341-350. Epub 2020 Jul 8.

Department of Radiation Oncology, University of California, San Francisco, San Francisco, USA.

Purpose: We aimed to examine utilization patterns of positron emission tomography scans (PET or PET/CT) beyond 6 months after cervical cancer treatment. We investigated survival outcomes of asymptomatic patients with PET-detected recurrence.

Methods: We performed a retrospective review of 283 patients with stage IA-IVA cervical cancer treated with primary chemoradiation. The 107 patients (37.8%) with recurrence were categorized as "asymptomatic PET-detected recurrence" (n = 23) or "standard detection" (n = 84) and we compared clinical characteristics and outcomes using multivariate logistic regression analysis.

Results: Late post-treatment PET (≥ 6 months after treatment) was performed in 35.3% (n = 100). Indications for late post-treatment PET included restaging in setting of known recurrence (23.6%), follow up of prior ambiguous imaging findings (9.7%), and new symptoms or exam findings (6.7%). However, late post-treatment PET was most commonly performed outside of current imaging guidelines, in asymptomatic patients without suspicion for recurrence (60.0%), presumably for surveillance. The median time to recurrence was 12.1 months (IQR 7.3-26.6). 23 patients (21.5%) had recurrence detected late post-treatment PET while asymptomatic (n = 23/107). Patients with asymptomatic PET-detected recurrence had improved survival by 26.3 months compared to the standard detection cohort (50.3 vs 24.0 months, p = 0.0015). On multivariate analysis, predictors of survival after recurrence were presence of distant metastases at diagnosis (p = 0.010) and asymptomatic PET-detected recurrence (p = 0.039).

Conclusions: PET imaging in asymptomatic patients beyond 6 months after treatment may have clinical benefit and warrants further study. Detection of recurrence by PET in asymptomatic patients ≥ 6 months after chemoradiation was associated with prolonged survival by more than   2 years.
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http://dx.doi.org/10.1007/s00261-020-02633-0DOI Listing
January 2021

Multiparametric Magnetic Resonance Imaging Alone is Insufficient to Detect Grade Reclassification in Active Surveillance for Prostate Cancer.

Eur Urol 2020 10 4;78(4):515-517. Epub 2020 Jul 4.

Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA. Electronic address:

Multiparametric magnetic resonance imaging (mpMRI) has improved the detection of clinically significant prostate cancer. It remains unclear, however, whether mpMRI can safely replace confirmatory or surveillance biopsies in men with low-risk disease managed with active surveillance (AS). Overall, 166 men were upgraded at a median of 29 mo (interquartile range 13-54). The overall negative predictive value (NPV) of mpMRI was 79.5% and ranged from 74.4% to 84.6% for all AS biopsies up to the fourth surveillance biopsy. In men with prostate-specific antigen density ≥0.15 ng/ml/cm, the overall NPV of mpMRI was 65.5% and ranged from 57.1% to 73.3% across serial mpMRI scans. These findings support the hypothesis that mpMRI is helpful but insufficient to rule out pathological reclassification, especially at confirmatory biopsy or in the presence of other risk factors. PATIENT SUMMARY: Multiparametric magnetic resonance imaging (mpMRI) alone misses a considerable percentage of clinically significant prostate cancers (Gleason grade group ≥2) in men on active surveillance for low-risk prostate cancer. We conclude that mpMRI alone cannot safely replace surveillance prostate biopsies, particularly at confirmatory biopsy or in the presence of other risk factors.
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http://dx.doi.org/10.1016/j.eururo.2020.06.030DOI Listing
October 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

Prostate MRI: staging and decision-making.

Abdom Radiol (NY) 2020 07;45(7):2143-2153

Division of Abdominal Radiology, Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA.

Multi-parametric prostate MRI (mpMRI) plays a critical role in the diagnosis, staging, and evaluation of treatment response in patients with prostate cancer. Radiologists, through an accurate and standardized interpretation of mpMRI, can clinically stage prostate cancer and help to risk stratify patients who may benefit from more invasive treatment or exclude patients who may be harmed by overtreatment. The purpose of this article is to describe key findings to accurately stage prostate cancer with mpMRI and to describe the contexts in which mpMRI is best applied.
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http://dx.doi.org/10.1007/s00261-020-02431-8DOI Listing
July 2020

MRI-Based Prostate-Specific Antigen Density Predicts Gleason Score Upgrade in an Active Surveillance Cohort.

AJR Am J Roentgenol 2020 03 8;214(3):574-578. Epub 2020 Jan 8.

Department of Urology, University of California, San Francisco, 1825 4th St, San Francisco, CA 94143-1695.

Elevated prostate-specific antigen density (PSAD) based on transrectal ultrasound (TRUS) measurements has been shown to be strongly associated with clinically significant disease and to predict progression on active surveillance (AS) for men with disease that is at a low stage or grade. We hypothesized that elevated MRI PSAD is similarly associated with increased risk of progression on subsequent biopsy. In this retrospective study, men with Gleason score of 3+3 on diagnostic TRUS-guided biopsy who were managed with AS, had undergone MRI, and had at least one additional biopsy were included. MRI PSAD was calculated using prostate volume on MRI and prostate-specific antigen level temporally closest to the MRI. Multivariable logistics regression models were used to evaluate the association between MRI PSAD and predictors of upgrade on serial biopsy. A total of 166 patients were identified, of whom 74 (44.6%) were upgraded to a Gleason score of 7 or higher on subsequent biopsy. Lesions with Prostate Imaging Reporting and Data System (PI-RADS) scores of 4 and 5 more commonly had MRI PSAD of 0.15 ng/mL or higher (51.93% vs 22.22%, = 0.01) than lesions with PI-RADS scores of 1-3. Median MRI PSAD was significantly higher in the upgraded group compared with the group that was not upgraded (0.15 ng/mL vs 0.11 ng/mL, = 0.01). MRI PSAD was significantly associated with increased odds of upgrading on subsequent biopsy (log transformation; odds ratio, 1.9 [95% CI, 1.2-2.8]; = 0.01) after adjusting for age and length of follow-up. MRI PSAD was significantly associated with Gleason score upgrading on subsequent biopsy for men initially diagnosed with Gleason 3+3 disease. Although this result is intuitive, to our knowledge it has not been previously shown. As MRI utilization increases, MRI PSAD can aid in risk stratification for men managed with AS.
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http://dx.doi.org/10.2214/AJR.19.21559DOI Listing
March 2020

Prognostic Value of Pretreatment MRI in Patients With Prostate Cancer Treated With Radiation Therapy: A Systematic Review and Meta-Analysis.

AJR Am J Roentgenol 2020 03 4;214(3):597-604. Epub 2019 Dec 4.

Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065.

Despite a substantial increase in the use of MRI for pretreatment evaluation of prostate cancer, its prognostic value in patients undergoing radiation therapy (RT) is not well known. Therefore, the purpose of this study was to systematically review the literature and perform a meta-analysis on the prognostic value of pretreatment MRI in patients with prostate cancer who underwent external beam radiation therapy (EBRT) or brachytherapy. PubMed and Embase databases were searched for studies published on or before March 13, 2019. We included studies that evaluated pretreatment MRI as a prognostic factor in prostate cancer regarding biochemical recurrence (BCR), metastatic failure, and overall or cancer-specific mortality. Effect sizes were measured in terms of the hazard ratio (HR) and were meta-analytically pooled using the random-effects model. The quality of the studies was independently evaluated using the Quality in Prognostic Studies tool. Twelve studies (2205 patients) were included. All studies assessed BCR; metastasis was evaluated in three studies, and mortality was evaluated in one study. Extraprostatic extension (EPE), seminal vesicle invasion (SVI), large tumor size or volume, number of sextants involved, and tumor involvement of prostatic apex were significant prognostic factors of BCR (pooled HRs = 1.50-4.47). EPE, larger tumor size, greater tumor volume, presence of metastatic pelvic lymph nodes (LNs), and presence of SVI were significant risk factors for metastasis (pooled HRs = 1.12-11.96). Pelvic LN metastasis was significantly predictive of cancer-specific mortality (HR = 4.45 [95% CI, 1.30-15.23]). Several pretreatment MRI findings were significant prognostic factors in patients with prostate cancer who underwent RT.
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http://dx.doi.org/10.2214/AJR.19.21836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499902PMC
March 2020

Prostate magnetic resonance imaging technique.

Abdom Radiol (NY) 2020 07;45(7):2109-2119

Department of Radiology and Biomedical Imaging, and Urology, Helen Diller Family Comprehensive Cancer Center, University of California, 505 Parnassus Avenue, M392, Box 0628, San Francisco, CA, 94941, USA.

Multiparametric magnetic resonance (MR) imaging of the prostate is an excellent tool to detect clinically significant prostate cancer, and it has widely been incorporated into clinical practice due to its excellent tissue contrast and image resolution. The aims of this article are to describe the prostate MR imaging technique for detection of clinically significant prostate cancer according to PI-RADS v2.1, as well as alternative sequences and basic aspects of patient preparation and MR imaging artifact avoidance.
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http://dx.doi.org/10.1007/s00261-019-02308-5DOI Listing
July 2020

Differences in negative predictive value of prostate MRI based in men with suspected or known cancer.

Radiol Bras 2019 Sep-Oct;52(5):281-286

University of California, San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, CA, USA.

Objective: To compare the negative predictive value (NPV) of multiparametric MRI for Gleason score (GS) ≥ 3+4 cancer and evaluate predictors of these tumors in men with suspected disease and under active surveillance (AS).

Materials And Methods: This retrospective study included 38 men with suspected prostate cancer and 38 under AS with scans assigned PI-RADS v2 scores 1 or 2 between May 2016 and September 2017. Biopsy results were no cancer, GS = 3+3, or GS ≥ 3+4. Pre-MRI PSA, gland volume, and PSA density were recorded. Chi-square, equality of proportions, and logistic regressions were used to analyze the data.

Results: Intermediate to high-grade cancer was found in 12.8% (95% CI = 2.3-23.3) and 35.9% (95% CI = 20.8-50.9) of men with suspected cancer, and under AS ( = 0.02), respectively. The NPV for GS ≥ 3+4 were 87.2% (suspected cancer; 76.7-97.7) and 64.1% (AS; 49.0-79.2). In neither group PSA significantly predicted cancer grade ( = 0.75 and 0.63). Although it did not reach conventional statistical significance, PSA density was a good predictor of cancer grade in men with suspected disease ( = 0.06), but not under AS ( = 0.62).

Conclusion: The NPV of multiparametric MRI for GS ≥ 3+4 is higher in men with suspected prostate cancer than in men under AS. PSA density ≤ 0.15 improved the prediction of intermediate to high-grade disease in patients without known cancer.
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http://dx.doi.org/10.1590/0100-3984.2018.0126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6808619PMC
October 2019

Lost in translation: lessons learned from the "demise" of MRSI of the prostate.

Abdom Radiol (NY) 2019 09;44(9):3185-3187

Department of Radiology and Biomedical Imaging, and Urology, University of California, San Francisco, 505 Parnassus Avenue, M-392, Box 0628, San Francisco, CA, 94143, USA.

At times, technologies fail for reasons other than an inability to deliver on their promises. The iconic Blackberry, for example, was once coined "Research in Motion", sold tens of millions of units, and then "disappeared" from the market because it did not accompany the new trends in design. Promising technologies may also "disappear" in the medical field. What follows is the tale of the rise and fall of proton magnetic resonance spectroscopic imaging (H MRSI) of the prostate.
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http://dx.doi.org/10.1007/s00261-019-02114-zDOI Listing
September 2019

The use of prostate MR for targeting prostate biopsies.

BJR Open 2019 19;1(1):20180044. Epub 2019 Jun 19.

Department of Radiology and Biomedical Imaging, University of California, San Francisco, California.

Management of prostate cancer relies heavily on accurate risk stratification obtained through biopsies, which are conventionally performed under transrectal ultrasound (TRUS) guidance. Yet, multiparametric MRI has grown to become an integral part of the care of males with known or suspected prostate cancer. This article will discuss in detail the different MRI-targeted biopsy techniques, their advantages and disadvantages, and the impact they have on patient management.
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http://dx.doi.org/10.1259/bjro.20180044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592478PMC
June 2019

Detection of clinically signifi cant prostate cancer with PIRADS v2 scores, PSA density, and ADC values in regions with and without mpMRI visible lesions.

Int Braz J Urol 2019 Jul-Aug;45(4):713-723

Department of Urology, University of California, San Francisco, CA, USA.

Purpose: To determine if PSAD, PSADtz, and ADC values improve the accuracy of PI-RADS v2 and identify men whose concurrent systematic biopsy detects clinically significant cancer on areas without mpMRI visible lesions.

Materials And Methods: Single reference-center, cross-sectional, retrospective study of consecutive men with suspected or known low to intermediate-risk prostate cancer who underwent 3T mpMRI and TRUS-MRI fusion biopsy from 07/15/2014 to 02/17/2018. Cluster-corrected logistic regression analyses were utilized to predict clinically significant prostate cancer (Gleason score ≥3+4) at targeted mpMRI lesions and on systematic biopsy.

Results: 538 men (median age=66 years, median PSA=7.0ng/mL) with 780mpMRI lesions were included. Clinically significant disease was diagnosed in 371 men. PI-RADS v2 scores of 3, 4, and 5 were clinically significant cancer in 8.0% (16/201), 22.8% (90/395), and 59.2% (109/184). ADC values, PSAD, and PI-RADS v2 scores were independent predictors of clinically significant cancer in targeted lesions (OR 2.25-8.78; P values <0.05; AUROC 0.84, 95% CI 0.81-0.87). Increases in PSAD were also associated with upgrade on systematic biopsy (OR 2.39-2.48; P values <0.05; AUROC 0.69, 95% CI 0.64-0.73).

Conclusions: ADC values and PSAD improve characterization of PI-RADS v2 score 4 or 5 lesions. Upgraded on systematic biopsy is slightly more likely with PSAD ≥0.15 and multiple small PI-RADS v2 score 3 or 4 lesions.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837611PMC
September 2019

Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.

AJR Am J Roentgenol 2019 Mar 5:1-7. Epub 2019 Mar 5.

1 Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, M-372, San Francisco, CA 94143-0628.

Objective: The objective of our study was to compare the quality of bowel opacification from three different positive oral contrast agents-barium sulfate, diatrizoate, and iohexol-at abdominopelvic CT.

Materials And Methods: Abdominopelvic CT examinations with three different oral contrast agents (each contrast agent: n = 300 patients) of 900 patients were retrospectively evaluated by two independent readers. For four segments of the gastrointestinal tract (i.e., the stomach, jejunum, ileum, and colon), readers recorded qualitative data (grade of nonuniform lumen opacification, types of inhomogeneous opacifications, presence of artifacts, and distribution of contrast agent) and quantitative data (CT attenuation of lumen [in Hounsfield units]). The results were compared among the three contrast agents using the Mann-Whitney U test and repeated-measures ANOVA with a post hoc Bonferroni correction.

Results: Fewer artifacts were detected with iohexol (4.3%) as the oral contrast agent than with diatrizoate (13.0%) and barium sulfate (14.3%) (each, p < 0.05). Barium showed a greater frequency of bowel lumen heterogeneity (388/831 segments, 47%) than iohexol (155/679, 23%) and diatrizoate (185/763, 24% segments) (p < 0.001). Barium showed higher CT attenuation than iohexol and diatrizoate in the stomach but lower CT attenuation in the ileum (each, p < 0.05).

Conclusion: The frequency of inhomogeneous bowel opacification was lower for iohexol than for diatrizoate or barium sulfate. Barium showed the highest frequency of bowel lumen heterogeneity. The iodinated agents showed greater increases in mean CT attenuation from the proximal bowel segments to the distal bowel segments than barium sulfate.
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http://dx.doi.org/10.2214/AJR.18.20445DOI Listing
March 2019

A Systematic Review of the Existing Prostate Imaging Reporting and Data System Version 2 (PI-RADSv2) Literature and Subset Meta-Analysis of PI-RADSv2 Categories Stratified by Gleason Scores.

AJR Am J Roentgenol 2019 04 26;212(4):847-854. Epub 2019 Feb 26.

3 Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave, M-392, San Francisco, CA 94143-0628.

Objective: The objective of this study was to quantitatively and qualitatively assess the methodologic heterogeneity of the current Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) literature and estimate the proportions of Gleason scores (GSs) diagnosed across PI-RADSv2 categories.

Materials And Methods: This study was a systematic review and meta-analysis and was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only English-language studies and studies published before April 1, 2018, were assessed. The primary outcome of the meta-analysis was the estimated percentage of patients with GS ≥ 3 + 4 within each individual PI-RADSv2 score. We calculated the pooled estimates and 95% CIs on the basis of a random-effects model using the meta-analysis routine of Stata (version 13.1).

Results: Our search revealed 434 titles, and 59 of these studies were selected. These studies were remarkable for their technical and terminological diverseness. Thirteen studies had sufficient data to be included in the meta-analysis. The prevalence of ≥ GS 3 + 4 in lesions assigned a PI-RADSv2 score of 3 or higher was approximately 45%. Lesions assigned PI-RADSv2 scores 1 or 2, 3, 4, and 5 represented high-grade disease in approximately 6%, 12%, 48%, and 72% of patients.

Conclusion: The data available in the literature are highly heterogeneous and challenging to analyze because of variations in terminology, patient cohort selection, criteria, imaging parameters, and reference standards. In spite of this heterogeneity, our meta-analysis shows that PI-RADSv2 has good sensitivity when a score of ≥ 3 is considered as a positive test.
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http://dx.doi.org/10.2214/AJR.18.20571DOI Listing
April 2019

Overcoming the challenges of imaging patients with metabolic syndrome.

Radiol Bras 2019 Jan-Feb;52(1):V-VI

MD PhD, Department of Radiology and Biomedical Imaging, and Urology, University of California San Francisco (UCSF), San Francisco, CA, USA. Email: https://orcid.org/0000-0003-0071-4989.

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http://dx.doi.org/10.1590/0100-3984.2019.52.1e1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383538PMC
February 2019

Impact of Staging Ga-PSMA-11 PET Scans on Radiation Treatment Plansin Patients With Prostate Cancer.

Urology 2019 03 21;125:154-162. Epub 2018 Dec 21.

University of California San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA; Department of Radiology, San Francisco VA Medical Center, San Francisco, CA. Electronic address:

Objective: To evaluate the impact of staging Ga-PSMA-11 PET imaging on radiotherapy (RT) dose and volumes in patients with prostate cancer.

Methods: Forty-five patients (89% high or very high risk by NCCN criteria) who underwent Ga-PSMA-11 PET imaging prior to definitive treatment for prostate cancer between December 2015 and December 2016 were included. Locations of Ga-PSMA-11-avid lesions were compared to Radiation Therapy Oncology Group consensus pelvic nodal volumes (clinical target volume [CTV]); coverage of lesions outside the consensus CTV was considered a major change, while dose-escalation to lesions within the consensus CTV was considered a minor change.

Results: All patients had Ga-PSMA-11 PET uptake in the prostate. Twenty-five patients (56%) had N1/M1a disease on Ga-PSMA-11 PET scan, of whom 21 (47%) were previously N0. Six patients (13%) had bone metastases on Ga-PSMA-11 PET scan, of whom 4 had prior negative bone scans. Eight patients (18%) had lymph node metastases outside the consensus CTV. Twelve patients (27%) received a RT boost to nodes within the consensus CTV. Six patients (13%) had limited bone metastases treated with focal RT. Overall PSMA PET imaging resulted in major and/or minor changes to RT plans in 24 patients (53%).

Conclusion: Ga-PSMA-11 PET imaging resulted in RT changes in 53% of patients. Prospective investigation is needed to evaluate the clinical benefit of RT changes based on staging Ga-PSMA-11 PET imaging.
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http://dx.doi.org/10.1016/j.urology.2018.09.038DOI Listing
March 2019

Can computer-aided diagnosis assist in the identification of prostate cancer on prostate MRI? a multi-center, multi-reader investigation.

Oncotarget 2018 Sep 18;9(73):33804-33817. Epub 2018 Sep 18.

Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.

For prostate cancer detection on prostate multiparametric MRI (mpMRI), the Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2) and computer-aided diagnosis (CAD) systems aim to widely improve standardization across radiologists and centers. Our goal was to evaluate CAD assistance in prostate cancer detection compared with conventional mpMRI interpretation in a diverse dataset acquired from five institutions tested by nine readers of varying experience levels, in total representing 14 globally spread institutions. Index lesion sensitivities of mpMRI-alone were 79% (whole prostate (WP)), 84% (peripheral zone (PZ)), 71% (transition zone (TZ)), similar to CAD at 76% (WP, p=0.39), 77% (PZ, p=0.07), 79% (TZ, p=0.15). Greatest CAD benefit was in TZ for moderately-experienced readers at PI-RADSv2 <3 (84% vs mpMRI-alone 67%, p=0.055). Detection agreement was unchanged but CAD-assisted read times improved (4.6 vs 3.4 minutes, p<0.001). At PI-RADSv2 ≥ 3, CAD improved patient-level specificity (72%) compared to mpMRI-alone (45%, p<0.001). PI-RADSv2 and CAD-assisted mpMRI interpretations have similar sensitivities across multiple sites and readers while CAD has potential to improve specificity and moderately-experienced radiologists' detection of more difficult tumors in the center of the gland. The multi-institutional evidence provided is essential to future prostate MRI and CAD development.
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http://dx.doi.org/10.18632/oncotarget.26100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173466PMC
September 2018

Uncommon malignant renal tumors and atypical presentation of common ones: a guide for radiologists.

Abdom Radiol (NY) 2019 04;44(4):1430-1452

Department of Diagnostic Radiology, University of California, San Francisco, 505 Parnassus, San Francisco, CA, 94122, USA.

Objective: While the typical imaging features of the more common RCC subtypes have previously been described, they can at times have unusual, but distinguishing features. Rarer renal tumors span a broad range of imaging features, but they may also have characteristic presentations. We review the key imaging features of atypical presentations of malignant renal tumors and uncommon malignant renal tumors.

Conclusion: Renal tumors have many different presentation patterns, but knowledge of the distinguishing MR and CT features can help identify both atypical presentation of common malignancies and uncommon renal tumors.
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http://dx.doi.org/10.1007/s00261-018-1789-4DOI Listing
April 2019

Diagnostic Accuracy of Ga-PSMA-11 PET/MRI Compared with Multiparametric MRI in the Detection of Prostate Cancer.

Radiology 2018 12 18;289(3):730-737. Epub 2018 Sep 18.

From the Department of Radiology and Biomedical Imaging (R.M.H., A.C.W., T.A.H.), Department of Anatomic Pathology (J.P.S.), Department of Urology (J.P.S., A.C.W., H.G.N., K.L.G., P.R.C.), and UCSF Helen Diller Family Comprehensive Cancer Center (A.C.W., L.Z., P.R.C., T.A.H.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628.

Purpose To compare the diagnostic accuracy of gallium 68 (Ga)-labeled prostate-specific membrane antigen (PSMA)-11 PET/MRI with that of multiparametric MRI in the detection of prostate cancer. Materials and Methods The authors performed a retrospective study of men with biopsy-proven prostate cancer who underwent simultaneous Ga-PSMA-11 PET/MRI before radical prostatectomy between December 2015 and June 2017. The reference standard was whole-mount pathologic examination. Readers were blinded to radiologic and pathologic findings. Tumor localization was based on 30 anatomic regions. Region-specific sensitivity and specificity were calculated for PET/MRI and multiparametric MRI by using raw stringent and alternative neighboring approaches. Maximum standardized uptake value (SUV) in the tumor and Prostate Imaging Reporting and Data System (PI-RADS) version 2 grade were compared with tumor Gleason score. Generalized estimating equations were used to estimate population-averaged sensitivity and specificity and to determine the association between tumor characteristics and SUV or PI-RADS score. Results Thirty-two men (median age, 68 years; interquartile range: 62-71 years) were imaged. The region-specific sensitivities of PET/MRI and multiparametric MRI were 74% (95% confidence interval [CI]: 70%, 77%) and 50% (95% CI: 45%, 0.54%), respectively, with the alternative neighboring approach (P < .001 for both) and 73% (95% CI: 68%, 79%) and 69% (95% CI: 62%, 75%), respectively, with the population-averaged generalized estimating equation (P = .04). Region-specific specificity of PET/MRI was similar to that of multiparametric MRI with the alternative neighboring approach (88% [95% CI: 85%, 91%] vs 90% [95% CI: 87%, 92%], P = .99) and in population-averaged estimates (70% [95% CI: 64%, 76%] vs 70% [95% CI: 64%, 75%], P = .99). SUV was associated with a Gleason score of 7 and higher (odds ratio: 1.71 [95% CI: 1.27, 2.31], P < .001). Conclusion The sensitivity of gallium 68-labeled prostate-specific membrane antigen-11 PET/MRI in the detection of prostate cancer is better than that of multiparametric MRI. © RSNA, 2018 See also the editorial by Civelek in this issue.
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http://dx.doi.org/10.1148/radiol.2018180788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6283324PMC
December 2018

Genomic Prostate Score, PI-RADS™ version 2 and Progression in Men with Prostate Cancer on Active Surveillance.

J Urol 2019 02;201(2):300-307

Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California.

Purpose: The OncotypeDx® GPS (Genomic Prostate Score®) is a 17-gene RNA expression assay intended to help guide treatment decisions in men diagnosed with prostate cancer. The PI-RADS™ (Prostate Imaging Reporting and Data System) version 2 was developed to standardize the risk stratification of lesions identified on multiparametric prostate magnetic resonance imaging. We sought to determine whether these tests are associated with an increased risk of biopsy upgrading in men on active surveillance.

Materials And Methods: We identified all patients on active surveillance at the University of California-San Francisco who had low/intermediate risk prostate cancer (prostate specific antigen 20 ng/ml or less and clinical stage T1/T2) and Gleason score 6 disease who underwent multiple biopsies and had a GPS available and/or had undergone multiparametric prostate magnetic resonance imaging with an available PI-RADS version 2 score. The primary study outcome was biopsy upgrading, defined as an increase in the Gleason score from 3 + 3 to 3 + 4 or greater, which was analyzed by Cox proportional hazards regression.

Results: Of the men 140 had only GPS test findings, 169 had only a PI-RADS version 2 score and 131 had both data. Each 5-unit increase in the GPS was associated with an increased risk of biopsy upgrading (HR 1.28, 95% CI 1.19-1.39, p <0.01). PI-RADS scores of 5 vs 1-2 (HR 4.38, 95% CI 2.36-8.16, p <0.01) and 4 vs 1-2 (HR 2.62, 95% CI 1.45-4.76, p <0.01) were also associated with an increased risk of a biopsy upgrade. On subanalysis of patients with GPS and PI-RADS version 2 scores the GPS was associated with biopsy upgrading, adding value to the clinical covariates (partial likelihood ratio p = 0.01).

Conclusions: A higher GPS or a PI-RADS version 2 score of 4 or 5 was associated with an increased risk of biopsy upgrading.
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http://dx.doi.org/10.1016/j.juro.2018.08.047DOI Listing
February 2019

Dual Energy Computed Tomography Scans of the Bowel: Benefits, Pitfalls, and Future Directions.

Radiol Clin North Am 2018 Sep;56(5):805-819

UCSF Department of Radiology, 505 Parnassus Avenue Box 0628, San Francisco, CA 94143-0628, USA.

Current computed tomography bowel imaging is challenging given the variable distension, content, and location of the bowel, the different appearance of tumors within and adjacent to bowel, and peristaltic artifacts. Published data remain sparse. Derangements in enhancement may be highlighted, image artifacts reduced, and radiation dose from multiphase scans minimized. This modality is suited for imaging bowel tumor detection and characterization, gastrointestinal bleeding, and bowel inflammation, and ischemia. Experimental results on computed tomography colonography and novel bowel contrast material offer hope for major improvements in bowel interrogation. It is likely to become increasingly valuable for bowel-related disease diagnosis and monitoring.
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http://dx.doi.org/10.1016/j.rcl.2018.05.002DOI Listing
September 2018

Multiparametric MR imaging of the Prostate: Interpretation Including Prostate Imaging Reporting and Data System Version 2.

Urol Clin North Am 2018 Aug;45(3):439-454

Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, M392, Box 0628, San Francisco, CA 94143, USA; Department of Urology, University of California San Francisco, 1825 4th Street, 4th Floor, Box 1711, San Francisco, CA 94143, USA. Electronic address:

mp-MRI of the prostate is a complex study that combines anatomic and functional imaging. The complexity of this technique, along with an increasing demand, has brought new challenges to imaging interpretation. The Prostate Imaging Reporting and Data System provides radiologists with guidelines to standardize interpretation. This article discusses the interpretation of the pulse sequences recommended in the Prostate Imaging Reporting and Data System version 2 guidelines, reviews advanced quantitative imaging tools, and discusses future directions.
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http://dx.doi.org/10.1016/j.ucl.2018.03.009DOI Listing
August 2018

Case series of collapsed simple renal cysts potentially simulating cystic malignancy at CT.

Clin Imaging 2018 Jul - Aug;50:297-301. Epub 2018 May 1.

Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L340, Portland, OR 97239, United States. Electronic address:

The radiological differential diagnosis for complex renal cysts seen at CT generally includes cystic malignancy or renal abscess. We have encountered five cases of complex-appearing renal cysts at CT where serial imaging and clinical outcome favored a diagnosis of a collapsed benign simple renal cyst. We present these cases to broaden the differential diagnosis for complex renal cysts seen at CT, highlighting the importance of careful correlation with prior imaging to assist in correct recognition of collapsed simple cysts and potentially allowing for conservative management or surveillance.
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http://dx.doi.org/10.1016/j.clinimag.2018.04.019DOI Listing
October 2018

CT and MRI of small renal masses.

Br J Radiol 2018 Jul 10;91(1087):20180131. Epub 2018 May 10.

1 Department of Radiology and Biomedical Imaging, University of California San Francisco , San Francisco, CA , USA.

Small renal masses are increasingly detected incidentally at imaging. They vary widely in histology and aggressiveness, and include benign renal tumors and renal cell carcinomas that can be either indolent or aggressive. Imaging plays a key role in the characterization of these small renal masses. While a confident diagnosis can be made in many cases, some renal masses are indeterminate at imaging and can present as diagnostic dilemmas for both the radiologists and the referring clinicians. This article will summarize the current evidence of imaging features that correlate with the biology of small solid renal masses, and discuss key approaches in imaging characterization of these masses using CT and MRI.
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http://dx.doi.org/10.1259/bjr.20180131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6221773PMC
July 2018

PI-RADS v2 and ADC values: is there room for improvement?

Abdom Radiol (NY) 2018 11;43(11):3109-3116

Department of Radiology, University of California San Francisco, San Francisco, CA, USA.

Purpose: To determine the diagnostic accuracy of ADC values in combination with PI-RADS v2 for the diagnosis of clinically significant prostate cancer (CS-PCa) compared to PI-RADS v2 alone.

Materials And Methods: This retrospective study included 155 men whom underwent 3-Tesla prostate MRI and subsequent MR/US fusion biopsies at a single non-academic center from 11/2014 to 3/2016. All scans were performed with a surface coil and included T2, diffusion-weighted, and dynamic contrast-enhanced sequences. Suspicious findings were classified using Prostate Imaging Reporting and Data System (PI-RADS) v2 and targeted using MR/US fusion biopsies. Mixed-effect logistic regression analyses were used to determine the ability of PIRADS v2 alone and combined with ADC values to predict CS-PCa. As ADC categories are more practical in clinical situations than numeric values, an additional model with ADC categories of ≤ 800 and > 800 was performed.

Results: A total of 243 suspicious lesions were included, 69 of which were CS-PCa, 34 were Gleason score 3+3 PCa, and 140 were negative. The overall PIRADS v2 score, ADC values, and ADC categories are independent statistically significant predictors of CS-PCa (p < 0.001). However, the area under the ROC of PIRADS v2 alone and PIRADS v2 with ADC categories are significantly different in both peripheral and transition zone lesions (p = 0.026 and p = 0.03, respectively) Further analysis of the ROC curves also shows that the main benefit of utilizing ADC values or categories is better discrimination of PI-RADS v2 4 lesions.

Conclusion: ADC values and categories help to diagnose CS-PCa when lesions are assigned a PI-RADS v2 score of 4.
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http://dx.doi.org/10.1007/s00261-018-1557-5DOI Listing
November 2018
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