Publications by authors named "Fergus V Coakley"

208 Publications

Performance of transgluteal CT-guided biopsy of prostate lesions in men without rectal access: A retrospective study.

Clin Imaging 2021 Jun 9;79:225-229. Epub 2021 Jun 9.

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

Objective: To retrospectively study the performance of CT-guided biopsy of target prostate lesions at a single institution.

Methods: Between May 2016 and February 2021, we retrospectively identified all men without rectal access who underwent transgluteal CT-guided biopsy of PIRADS 4 or 5 targets detected on multiparametric MRI (n = 9). Clinical, radiological, and pathological details were collected by review of the electronic medical record, and included age, pre-biopsy prostate specific antigen (PSA) value, prior biopsy history, biopsy targeting technique and procedural details, complications, and final histologic diagnosis. Two targeting techniques were used: Localizing with anatomic landmarks or localizing with contrast enhancement.

Results: Mean patient age was 69 years (range, 49-74) and mean PSA was 14.6 ng/mL (range 7-23). Four lesions were targeted using anatomic landmarks and 5 were targeted using contrast enhancement. All biopsies were technically successful and all resulted as prostate cancer. Three biopsies showed Gleason 6 cancer and 6 biopsies showed clinically significant prostate cancers with Gleason 7 or above. There were no major complications. 7 patients went on to definitive treatment with surgery or radiation.

Conclusion: Transgluteal CT-guided biopsy of MRI detected prostate lesions diagnoses clinically significant prostate cancer without complication and therefore should be considered for patients without a rectum.
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http://dx.doi.org/10.1016/j.clinimag.2021.06.004DOI Listing
June 2021

In-Bore Versus Fusion MRI-Targeted Prostate Biopsy of PI-RADS Category 4 or 5 Lesions: A Retrospective Comparative Analysis Using Propensity Score Weighting.

AJR Am J Roentgenol 2021 Mar 1. Epub 2021 Mar 1.

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

Few published studies have compared in-bore and fusion MRI-targeted prostate biopsy, with conflicting results. To compare the target-specific cancer detection rate of in-bore versus fusion MRI-targeted biopsy. We retrospectively identified men who underwent in-bore or fusion MRI-targeted biopsy of PI-RADS category 4 or 5 lesions between August 2013 and September 2019. PI-RADS version 2.1 score, size, and location of each target were established by retrospective review by a single experienced radiologist. Patient history and target biopsy results were obtained by electronic medical record review. Only the first MRI-targeted biopsy of the dominant lesion was included for patients with repeated biopsies or multiple targets. Inbore and fusion biopsy were compared using propensity score weights and multivariable regression to adjust for imbalances in patient and target characteristics between biopsy techniques. The primary endpoint was target-specific prostate cancer detection rate. Secondary endpoints included detection rates after applying propensity score weighting for International Society of Urologic Pathology (ISUP) Grade Group (GG) 2 and above cancer, as well as when including off-target systematic sampling results. The study sample included 286 men (191 and 95 men who underwent in-bore and fusion biopsy, respectively). In-bore biopsy had a significantly higher likelihood of detecting any cancer (odds ratio = 2.28, 95% CI 1.04 - 4.98; p=.04), and a non-significantly higher likelihood of detecting ISUP GG2 or above cancer (odds ratio = 1.57, 95% CI 0.88 - 2.79; p = .12), in a target compared to fusion biopsy. When including off-target sampling, in-bore biopsy and combined fusion and systematic biopsy were not different for detection of any cancer (odds ratio = 1.16, 95% CI 0.54 - 2.45; p = .71) or ISUP GG2 and above cancer (odds ratio = 1.15, 95% CI 0.66 - 2.01; p = .62). In this retrospective study using propensity score weighting, in-bore MRI-targeted prostate biopsy had higher target-specific cancer detection rate compared to fusion biopsy. Pending a larger prospective randomized multicenter comparison between in-bore and fusion biopsy, in-bore may be the preferred approach should performing only biopsy of a suspicious target, without concurrent systematic biopsy, be considered clinically appropriate.
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http://dx.doi.org/10.2214/AJR.20.25207DOI Listing
March 2021

MRI of prostatic urethral mucinous urothelial carcinoma: Expanding the differential diagnosis for T2 hyperintense prostatic masses.

Clin Imaging 2020 Dec 16;68:68-70. Epub 2020 Jun 16.

Department of Diagnostic Radiology (NP, BRF EKK, KJ, FVC), Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR 97239, United States of America; Department of Pathology (KRT), Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR 97239, United States of America.

We report the case of a 66-year-old previously healthy man presenting with blood and mucus in his urine. Cystoscopy revealed a mass in the prostatic urethra, and endoscopic biopsy showed adenocarcinoma in situ with mucinous features. Endorectal multiparametric prostate MRI demonstrated a 1.9 cm T2 hyperintense mass in the peripheral zone of the left prostatic apex with extension into the urethral lumen. No diffusion restriction or early enhancement was seen in the mass. Radical prostatectomy was performed, and final pathology demonstrated a mucin-producing urothelial adenocarcinoma arising from the prostatic urethra. The peripheral zone T2 hyperintense abnormality correlated with abundant pools of mucin extending into the prostatic stroma and surrounded by neoplastic prostatic glandular cells. We conclude prostatic urethral mucinous urothelial carcinoma should be included in the differential diagnosis for T2 hyperintense prostatic masses.
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http://dx.doi.org/10.1016/j.clinimag.2020.06.012DOI Listing
December 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

Impact of Direct MRI-Guided Biopsy of the Prostate on Clinical Management.

AJR Am J Roentgenol 2019 08 1;213(2):371-376. Epub 2019 Apr 1.

1 Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code L340, Portland, OR 97239.

The purpose of this study is to investigate the impact of direct MRI-guided biopsy of the prostate on clinical management in practice. We retrospectively identified 127 patients with unknown ( = 98) or untreated prostate cancer with a Gleason score of 6 ( = 29) who underwent direct MRI-guided biopsy of the prostate at our institution between August 2013 and January 2018, after initial multiparametric endorectal MRI examination revealed one or more Prostate Imaging Reporting and Data System (PI-RADS or PI-RADSv2) category 4 or 5 target lesion. All available medical and imaging records were reviewed to determine pertinent clinical details, biopsy findings, and postbiopsy management. The mean patient age was 68 years (interquartile range, 63-73 years). Findings from MRI-guided biopsy were positive for 93 of 127 patients (73%), with prostate cancer of Gleason score of 7 or higher diagnosed in 84 of these 93 patients (90%). When stratified by clinical scenario, the rate of positive biopsy findings was 66% (57/86) for patients who had negative findings from one or more prior transrectal ultrasound-guided biopsies, 83% (10/12) for biopsy-naive patients, and 90% (26/29) for patients undergoing active surveillance. Overall, 90 of 127 patients (71%) received a new ( = 67) or upgraded ( = 23) diagnosis of prostate cancer, and 57 of these 90 patients (63%) proceeded to receive treatment with prostatectomy, radiation, or androgen deprivation therapy. The results of this study suggest that direct MRI-guided biopsy is associated with high rates of significant prostate cancer detection and subsequent definitive treatment across common clinical scenarios and should be considered an important supplementary diagnostic tool in the appropriate setting.
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http://dx.doi.org/10.2214/AJR.18.21009DOI Listing
August 2019

MRI of prolapsed polypoid adenomyoma: Expanding the differential diagnosis for the broccoli sign.

Clin Imaging 2018 Nov - Dec;52:177-179. Epub 2018 Aug 4.

Departments of Diagnostic Radiology (NP, RS, FVC), Obstetrics and Gynecology (JH), Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L340, Portland, OR 97239, United States. Electronic address:

We report a 44 year old previously healthy premenopausal woman who presented with a three month history of vaginal bleeding and a 5 cm vaginal mass obscuring the cervix on physical examination. Ultrasound evaluation was non diagnostic. Pelvic MRI demonstrated a 6 cm soft tissue mass in the vagina prolapsed from the uterine cavity with a visible connecting stalk, which is termed the broccoli sign. The initial radiological differential diagnosis included prolapsed uterine malignancy or leiomyoma. Surgical pathology revealed a polypoid adenomyoma. We conclude polypoid adenomyoma should be included in the differential diagnosis for prolapsed uterine tumor demonstrating the broccoli sign.
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http://dx.doi.org/10.1016/j.clinimag.2018.08.001DOI Listing
January 2019

Dominant intraprostatic cancer confirmed by direct MRI-guided biopsy: Concordance with histopathological findings.

Clin Imaging 2018 Sep - Oct;51:273-278. Epub 2018 Jun 9.

Department of Diagnostic Radiology, Oregon Health & Science University, United States. Electronic address:

Purpose: To investigate the concordance between dominant intraprostatic cancer seen on endorectal multiparametric MRI and confirmed by MRI-targeted biopsy with histopathological findings at radical prostatectomy, since existing literature has emphasized the miss rather than the concordance rate of MRI.

Materials And Methods: We retrospectively identified 20 patients who underwent radical prostatectomy after a dominant intraprostatic cancer focus was identified at endorectal multiparametric MRI and confirmed by MRI-targeted biopsy. Concordance was determined by comparing the location and Gleason grade group of dominant tumor at MRI with the location and Gleason grade group determined at histopathological review.

Results: Mean patient age was 65 years (range, 48 to 76) and median serum prostatic specific antigen level was 9.4 ng/mL (range, 4.6 to 58.0). In all 20 patients, the location of dominant tumor based on MRI and targeted biopsy corresponded with the dominant tumor location at histopathology. In 9 patients, Gleason grade group was the same at targeted biopsy and final histopathology. In 9 patients, final Gleason grade group was higher and in two patients it was lower.

Conclusion: Our preliminary results suggest dominant tumor as determined by endorectal multiparametric MRI and confirmed by a positive MRI-targeted biopsy has high concordance with histopathological findings at radical prostatectomy for location, and reasonable concordance for Gleason grade group.
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http://dx.doi.org/10.1016/j.clinimag.2018.06.008DOI Listing
November 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

Endorectal MR imaging of prostate cancer: Evaluation of tumor capsular contact length as a sign of extracapsular extension.

Clin Imaging 2018 Jul - Aug;50:280-285. Epub 2018 Apr 25.

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

Objective: To evaluate the length of contact between dominant tumor foci and the prostatic capsule as a sign of extracapsular extension at endorectal multiparametric MR imaging.

Materials And Methods: We retrospectively identified 101 patients over a three-year interval who underwent endorectal multiparametric prostate MR imaging prior to radical prostatectomy for prostate cancer. Two readers identified the presence of dominant tumor focus (largest lesion with PI-RADS version 2 score of 4 or 5), and measured the length of tumor capsular contact and likelihood of extracapsular extension by standard criteria (1-5 Likert scale). Results were analyzed using histopathological review as reference standard.

Results: Extracapsular extension was found at histopathological review in 27 patients. Reader 1 (2) identified dominant tumor in 79 (73) patients, with mean tumor capsular contact length of 18.2 (14.0) mm. The area under the receiver operating characteristic curve for identification of extracapsular extension by tumor capsular contact length was 0.76 for reader 1 and 0.77 for reader 2, with optimal discrimination at values of 18 mm and 21 mm, respectively. In the subset of patients without obvious extracapsular extension by standard criteria (Likert scores 1-3), corresponding values were 0.74 and 0.66 with optimal thresholds of 24 and 21 mm.

Conclusion: Length of contact between the dominant tumor focus and the capsule is a moderately useful sign of extracapsular extension at endorectal multiparametric prostate MR imaging, including the subset of patients without obvious extracapsular extension by standard criteria, with optimal discrimination at threshold values of 18 to 24 mm.
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http://dx.doi.org/10.1016/j.clinimag.2018.04.020DOI 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

Direct magnetic resonance imaging-guided biopsy of the prostate: lessons learned in establishing a regional referral center.

Transl Androl Urol 2017 Jun;6(3):395-405

Departments of Diagnostic Radiology (BA, BRF, AF, CJ, FVC) and Urology (CLA), Oregon Health & Science University, L340, Portland, OR 97239, USA.

MRI-targeted biopsy of the prostate appears to have the potential to reduce the high rates of underdiagnosis and overdiagnosis associated with the current diagnostic standard of transrectal ultrasound guided systematic biopsy. Direct or "in bore" MRI-guided biopsy is one of the three methods for MRI-targeted core needle sampling of suspicious, generally Pi-RADS 4 or 5, foci within the prostate, and our early experience suggests the approach demonstrates substantial utility and promise in the care of patients with prostate cancer. We performed direct MRI-guided biopsies in 50 patients within 19 months of establishing the first referral center for this service in our region. Our preliminary results indicate the service can be easily grown due to unmet demand, primarily in patients with a negative traditional systematic biopsy but with a concerning focus at MRI (30 of 50; 60%). Other applications include evaluation of patients who are on active surveillance (n=14; ten upgraded to higher Gleason score at MRI-guided biopsy), who are biopsy naïve (n=5; all positive at MRI-guided biopsy), or post focal therapy (n=1; positive for recurrent tumor at MRI-guided biopsy). With careful patient selection and technique, we have achieved a favorable overall positive biopsy rate of 73% (37 of 50), with 84% (31 of 37) positive biopsies demonstrating Gleason score 7 or greater disease. Large multicenter comparative trials will be required to determine the relative accuracy and appropriate utilization of direct MRI guided biopsy in the care pathway of patients with known or suspected prostate cancer.
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http://dx.doi.org/10.21037/tau.2017.01.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503963PMC
June 2017

Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis.

Pediatr Radiol 2017 Sep 19;47(10):1312-1320. Epub 2017 Jun 19.

Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.

Background: Magnetic resonance imaging (MRI) has emerged as a promising modality for evaluating pediatric appendicitis. However optimal imaging protocols, including roles of contrast agents and sedation, have not been established and diagnostic criteria have not been fully evaluated.

Objective: To investigate performance characteristics of rapid MRI without contrast agents or sedation in the diagnosis of pediatric appendicitis.

Materials And Methods: We included patients ages 4-18 years with suspicion of appendicitis who underwent rapid MRI between October 2013 and March 2015 without contrast agent or sedation. After two-radiologist review, we determined performance characteristics of individual diagnostic criteria and aggregate diagnostic criteria by comparing MRI results to clinical outcomes. We used receiver operating characteristic (ROC) curves to determine cut-points for appendiceal diameter and wall thickness for optimization of predictive power, and we calculated area under the curve (AUC) as a measure of test accuracy.

Results: Ninety-eight MRI examinations were performed in 97 subjects. Overall, MRI had a 94% sensitivity, 95% specificity, 91% positive predictive value and 97% negative predictive value. Optimal cut-points for appendiceal diameter and wall thickness were ≥7 mm and ≥2 mm, respectively. Independently, those cut-points produced sensitivities of 91% and 84% and specificities of 84% and 43%. Presence of intraluminal fluid (30/33) or localized periappendiceal fluid (32/33) showed a significant association with acute appendicitis (P<0.01), with sensitivities of 91% and 97% and specificities of 60% and 50%. For examinations in which the appendix was not identified by one or both reviewers (23/98), the clinical outcome was negative.

Conclusion: Rapid MRI without contrast agents or sedation is accurate for diagnosis of pediatric appendicitis when multiple diagnostic criteria are considered in aggregate. Individual diagnostic criteria including optimized cut-points of ≥7 mm for diameter and ≥2 mm for wall thickness demonstrate high sensitivities but relatively low specificities. Nonvisualization of the appendix favors a negative diagnosis.
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http://dx.doi.org/10.1007/s00247-017-3897-7DOI Listing
September 2017

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

ACR Appropriateness Criteria Hematospermia.

J Am Coll Radiol 2017 May;14(5S):S154-S159

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

Most men with hematospermia or hemospermia (HS) are young (<40 years of age), presenting with transient or episodic HS without other signs or symptoms of disease. The condition is self-limiting in most cases and idiopathic in nature. When a cause can be identified, infections of the urogenital tract are the most common. Imaging does not play a role in this patient population. In older men (>40 years of age), clinical screening for prostate cancer is advised. Furthermore, when HS is persistent or has symptoms, causes include obstruction or stricture at the level of the verumontanum, calcifications or calculi in the prostate, ejaculatory ducts or seminal vesicles, and cysts arising within these structures. Noninvasive imaging, predominantly transrectal ultrasound (TRUS) and MRI, can be used in men of any age with persistent or refractory HS, or other associated symptoms or signs. TRUS is considered as the first-line imaging with MRI used when TRUS is inconclusive or negative. 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.2017.02.023DOI Listing
May 2017

ACR Appropriateness Criteria Staging of Testicular Malignancy.

J Am Coll Radiol 2016 Oct 12;13(10):1203-1209. Epub 2016 Aug 12.

University of New Mexico, Albuquerque, New Mexico.

Testicular cancer represents only 1% of all malignancies occurring in men. However, it is the most frequent malignancy in men between the ages of 20 and 34 years, accounting for 10% to 14% of cancer incidence in that age group. In most instances, the diagnosis of testicular tumors is established with a carefully performed physical examination and scrotal ultrasonography. Tumor markers are useful for determining the presence of residual disease. Cross-sectional imaging studies (CT, MRI) are useful in determining the location of metastases. Chest radiography and CT are used to assess pulmonary disease. Fluorine-18-2-fluoro-2-deoxy-d-glucose (FDG) PET scans have slightly higher sensitivity than CT, but their role in staging testicular cancer has not been determined in a large study. FDG PET may play a role in the follow-up of higher stage seminoma after chemotherapy. Bone scans are useful in the absence of FDG PET scans and should be used when bone metastases are suspected. The ACR 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 (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which 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.2016.06.026DOI Listing
October 2016

Radiological appearances of corpus luteum cysts and their imaging mimics.

Abdom Radiol (NY) 2016 11;41(11):2270-2282

Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L340, Portland, OR, 97239, USA.

Purpose: To review the radiological appearances of corpus luteum cysts and their imaging mimics.

Conclusion: Corpus luteum cysts are normal post-ovulatory structures seen in the ovaries through the second half of the menstrual cycle and the first trimester of pregnancy. The typical appearance, across all modalities, is of a 1- to 3-cm cyst with a thick crenulated vascularized wall. Occasionally, similar imaging findings may be seen with endometrioma, ectopic pregnancy, tuboovarian abscess, red degeneration of a fibroid, and ovarian neoplasia. In most cases, imaging findings are distinctive and allow for a confident and accurate diagnosis that provides reassurance for patients and referring physicians and avoids costly unnecessary follow-up.
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http://dx.doi.org/10.1007/s00261-016-0780-1DOI Listing
November 2016

Beyond Prostate Adenocarcinoma: Expanding the Differential Diagnosis in Prostate Pathologic Conditions.

Radiographics 2016 Jul-Aug;36(4):1055-75. Epub 2016 Jun 17.

From the Department of Radiology and Biomedical Imaging (Y.L., J.M., S.C.B., A.C.W.) and Department of Pathology (J.S.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Sir Ganga Ram Hospital, New Delhi, India (S.S.); and Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Ore (F.V.C.).

Recent advances in magnetic resonance (MR) imaging of the prostate gland have dramatically improved the ability to detect and stage adenocarcinoma of the prostate, one of the most frequently diagnosed cancers in men and one of the most frequently diagnosed pathologic conditions of the prostate gland. A wide variety of nonadenocarcinoma diseases can also be seen with MR imaging, ranging from benign to malignant diseases, as well as infectious and inflammatory manifestations. Many of these diseases have distinctive imaging features that allow differentiation from prostate acinar adenocarcinoma. Early recognition of these entities produces a more accurate differential diagnosis and may enable more expeditious clinical workup. Benign neoplasms of the prostate include plexiform neurofibroma and cystadenoma, both of which demonstrate distinctive imaging features. Stromal neoplasms of uncertain malignant potential are rare tumors of uncertain malignant potential that are often difficult to distinguish at imaging from more-malignant prostate sarcomas. Other malignant neoplasms of the prostate include urothelial carcinoma, primary prostatic carcinoid, carcinosarcoma, endometrioid or ductal adenocarcinoma, and mucinous adenocarcinoma. Prostatic infections can lead to abscesses of pyogenic, tuberculous, or fungal origins. Finally, miscellaneous idiopathic disorders of the prostate include amyloidosis, exophytic benign prostatic hyperplasia, and various congenital cysts. Considerable overlap can exist in the clinical history and imaging findings associated with these prostate pathologic conditions, and biopsy is often required for ultimate confirmation of the diagnosis. However, many diagnoses, including cystadenoma, mucinous adenocarcinoma, sarcoma, and abscesses, have distinct imaging features, which can enable the informed radiologist to identify the diagnosis and recommend appropriate clinical workup and management. (©)RSNA, 2016.
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http://dx.doi.org/10.1148/rg.2016150226DOI Listing
March 2017

Relative sensitivities of DCE-MRI pharmacokinetic parameters to arterial input function (AIF) scaling.

J Magn Reson 2016 08 28;269:104-112. Epub 2016 May 28.

Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR 97239, United States.

Dynamic-Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) has been used widely for clinical applications. Pharmacokinetic modeling of DCE-MRI data that extracts quantitative contrast reagent/tissue-specific model parameters is the most investigated method. One of the primary challenges in pharmacokinetic analysis of DCE-MRI data is accurate and reliable measurement of the arterial input function (AIF), which is the driving force behind all pharmacokinetics. Because of effects such as inflow and partial volume averaging, AIF measured from individual arteries sometimes require amplitude scaling for better representation of the blood contrast reagent (CR) concentration time-courses. Empirical approaches like blinded AIF estimation or reference tissue AIF derivation can be useful and practical, especially when there is no clearly visible blood vessel within the imaging field-of-view (FOV). Similarly, these approaches generally also require magnitude scaling of the derived AIF time-courses. Since the AIF varies among individuals even with the same CR injection protocol and the perfect scaling factor for reconstructing the ground truth AIF often remains unknown, variations in estimated pharmacokinetic parameters due to varying AIF scaling factors are of special interest. In this work, using simulated and real prostate cancer DCE-MRI data, we examined parameter variations associated with AIF scaling. Our results show that, for both the fast-exchange-limit (FXL) Tofts model and the water exchange sensitized fast-exchange-regime (FXR) model, the commonly fitted CR transfer constant (K(trans)) and the extravascular, extracellular volume fraction (ve) scale nearly proportionally with the AIF, whereas the FXR-specific unidirectional cellular water efflux rate constant, kio, and the CR intravasation rate constant, kep, are both AIF scaling insensitive. This indicates that, for DCE-MRI of prostate cancer and possibly other cancers, kio and kep may be more suitable imaging biomarkers for cross-platform, multicenter applications. Data from our limited study cohort show that kio correlates with Gleason scores, suggesting that it may be a useful biomarker for prostate cancer disease progression monitoring.
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http://dx.doi.org/10.1016/j.jmr.2016.05.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958517PMC
August 2016

Revised Atlanta Classification for Acute Pancreatitis: A Pictorial Essay.

Radiographics 2016 May-Jun;36(3):675-87

From the Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (B.R.F., K.K.J., G.B., F.V.C.); and Department of Radiology, University of Utah, Salt Lake City, Utah (A.M.S.).

The 2012 revised Atlanta classification is an update of the original 1992 Atlanta classification, a standardized clinical and radiologic nomenclature for acute pancreatitis and associated complications based on research advances made over the past 2 decades. Acute pancreatitis is now divided into two distinct subtypes, necrotizing pancreatitis and interstitial edematous pancreatitis (IEP), based on the presence or absence of necrosis, respectively. The revised classification system also updates confusing and sometimes inaccurate terminology that was previously used to describe pancreatic and peripancreatic collections. As such, use of the terms acute pseudocyst and pancreatic abscess is now discouraged. Instead, four distinct collection subtypes are identified on the basis of the presence of pancreatic necrosis and time elapsed since the onset of pancreatitis. Acute peripancreatic fluid collections (APFCs) and pseudocysts occur in IEP and contain fluid only. Acute necrotic collections (ANCs) and walled-off necrosis (WON) occur only in patients with necrotizing pancreatitis and contain variable amounts of fluid and necrotic debris. APFCs and ANCs occur within 4 weeks of disease onset. After this time, APFCs or ANCs may either resolve or persist, developing a mature wall to become a pseudocyst or a WON, respectively. Any collection subtype may become infected and manifest as internal gas, though this occurs most commonly in necrotic collections. In this review, the authors present a practical image-rich guide to the revised Atlanta classification system, with the goal of fostering implementation of the revised system into radiology practice, thereby facilitating accurate communication among clinicians and reinforcing the radiologist's role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. (©)RSNA, 2016.
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http://dx.doi.org/10.1148/rg.2016150097DOI Listing
March 2017

A Modified Approach for Transgluteal Prostate Biopsy in Patients Without Rectal Access.

AJR Am J Roentgenol 2016 08 4;207(2):W20. Epub 2016 May 4.

1 Oregon Health and Science University, Portland, OR.

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http://dx.doi.org/10.2214/AJR.16.16113DOI Listing
August 2016

Endorectal multiparametric MRI of the prostate: incremental effect of perfusion imaging on biopsy target identification.

Clin Imaging 2016 May-Jun;40(3):553-7. Epub 2016 Jan 28.

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

Purpose: To evaluate the incremental effect of perfusion imaging on biopsy target identification at endorectal multiparametric prostate magnetic resonance imaging (MRI).

Materials And Methods: We retrospectively 52 patients who underwent endorectal multiparametric prostate MRI for suspected or untreated prostate cancer. Two readers independently identified biopsy targets without and with perfusion images.

Results: Reader 1 identified 36 targets without and 39 targets with perfusion imaging (P>.05). The corresponding numbers for reader 2 were 38 and 38, respectively (P=.5).

Conclusion: Perfusion imaging does not significantly increase the number of biopsy targets identified at endorectal multiparametric prostate MRI.
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http://dx.doi.org/10.1016/j.clinimag.2016.01.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853829PMC
December 2016

Prostate cancer with a pseudocapsule at MR imaging: a marker of high grade and stage disease?

Clin Imaging 2016 May-Jun;40(3):365-9. Epub 2016 Jan 21.

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

Clinicopathological correlates of prostate cancer associated with a pseudocapsule at T2-weighted magnetic resonance (MR) imaging are presented in a retrospective series of 15 patients. Of 15 tumors, 14 involved the peripheral zone. Extracapsular extension was seen in 14 cases. Tumor Gleason score was 8 or above in 12 of 15 cases, and ductal type adenocarcinoma was identified in 4 cases. Step section histopathological correlation (n=5) demonstrated that the pseudocapsule corresponded with dense compressive or reactive peritumoral fibrosis. A pseudocapsule around prostate cancer at T2-weighted MR imaging is a rare finding that appears to be associated with high grade and stage disease.
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http://dx.doi.org/10.1016/j.clinimag.2015.12.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853654PMC
December 2016

PROMISe trial: a pilot, randomized, placebo-controlled trial of magnetic resonance guided focused ultrasound for uterine fibroids.

Fertil Steril 2016 Mar 1;105(3):773-780. Epub 2015 Dec 1.

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

Objective: To evaluate the feasibility of a full-scale placebo-controlled trial of magnetic resonance-guided focused ultrasound for fibroids (MRgFUS) and obtain estimates of safety and efficacy.

Design: Pilot, randomized, placebo-controlled trial.

Setting: University medical center.

Patient(s): Premenopausal women with symptomatic uterine fibroids.

Intervention(s): Participants randomized in a 2:1 ratio to receive MRgFUS or placebo procedure.

Main Outcome Measure(s):

Primary Outcome: change in fibroid symptoms from baseline to 4 and 12 weeks after treatment assessed by the Uterine Fibroid Symptom Quality of Life Questionnaire (UFS-QOL); secondary outcome: incidence of surgery or procedures for recurrent symptoms at 12 and 24 months.

Result(s): Twenty women with a mean age of 44 years (±standard deviation 5.4 years) were enrolled, and 13 were randomly assigned to MRgFUS and 7 to placebo. Four weeks after treatment, all participants reported improvement in the UFS-QOL: a mean of 10 points in the MRgFUS group and 9 points in the placebo group (for difference in change between groups). By 12 weeks, the MRgFUS group had improved more than the placebo group (mean 31 points and 13 points, respectively). The mean fibroid volume decreased 18% in the MRgFUS group with no decrease in the placebo group at 12 weeks. Two years after MRgFUS, 4 of 12 women who had a follow-up evaluation (30%) had undergone another fibroid surgery or procedure.

Conclusion(s): Women with fibroids were willing to enroll in a randomized, placebo-controlled trial of MRgFUS. A placebo effect may explain some of the improvement in fibroid-related symptoms observed in the first 12 weeks after MRgFUS.

Clinical Trial Registration Number: NCT01377519.
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http://dx.doi.org/10.1016/j.fertnstert.2015.11.014DOI Listing
March 2016

Metastatic renal cell carcinoma without evidence of a renal primary.

Int Urol Nephrol 2016 Jan 2;48(1):73-7. Epub 2015 Nov 2.

Department of Pathology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L418, Portland, OR, 97239, USA.

Purpose: Metastatic renal cell carcinoma (RCC), without an identified kidney primary, has been reported rarely. We report a patient with RCC metastatic to bilateral adrenal glands and liver, without an apparent renal primary. We detail the immunohistochemical and molecular studies employed to substantiate the diagnosis of RCC and direct therapy.

Methods: Histopathologic findings were correlated with imaging data and supplemented by a panel of immunohistochemical stains, as well as tumor sequence analysis.

Results: Despite the presence of bilateral adrenal masses and lack of tumor within kidney parenchyma, the diagnosis of RCC was substantiated by immunohistochemistry (RCC+/PAX2+/PAX8+/Melan-A-/SF-1- among others) and molecular genetic analysis, harboring mutations in VHL, TP53, KDM5C, and PBRM1. After debulking surgery, based on the diagnosis of RCC and the molecular profile, the patient was treated with a tyrosine kinase inhibitor (sunitinib), resulting in stablilization of disease.

Conclusions: This case illustrates the role of mutational analysis in carcinomas with rare or unusual presentations, such as metastatic RCC without a renal primary.
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http://dx.doi.org/10.1007/s11255-015-1145-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772903PMC
January 2016

Direct MRI-guided biopsy of the prostate: use of post-biopsy needle track imaging to confirm targeting.

Abdom Imaging 2015 Oct;40(7):2517-22

Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR, 97239, USA.

Purpose: To report the observation that in-plane post-biopsy T2-weighted MRI often demonstrates the needle track as a transient visible linear tissue distortion during direct MRI-guided biopsy.

Materials And Methods: We retrospectively identified 11 prostatic lesions in 9 men that underwent direct MRI-guided biopsy and in which post-biopsy images were obtained in the plane of the biopsy needle.

Results: In 9 of 11 targets, a post-biopsy needle track was visible as a linear tissue distortion on in-plane T2-weighted images obtained at a mean interval of 6 min (range 3-15). In these nine cases, the needle track traversed the intended target, and the biopsy was positive for malignancy in six. Biopsy was positive in one of two cases where the needle track was not visible. In five targets, one or more delayed series were obtained after a mean interval of 21 min (range 8-33), showing the track was no longer visible (n = 3) or was of progressively decreased conspicuity (n = 2).

Conclusion: Accurate targeting during direct MRI-guided biopsy of the prostate can be confirmed by obtaining post-biopsy in-plane images, since the needle track is usually visible as a transient linear tissue distortion.
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http://dx.doi.org/10.1007/s00261-015-0382-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539289PMC
October 2015

Computed tomography of iatrogenic complications of upper gastrointestinal endoscopy, stenting, and intubation.

Radiol Clin North Am 2014 Sep 3;52(5):1055-70. Epub 2014 Jul 3.

Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA. Electronic address:

Intraluminal procedures for the gastrointestinal tract range from simple intubation for feeding or bowel decompression to endoscopic procedures including stenting and pancreatobiliary ductal catheterization. Each of these procedures and interventions carries a risk of iatrogenic injury, including bleeding, perforation, infection, adhesions, and obstruction. An understanding of how anatomy and function may predispose to injury, and the distinct patterns of injury, can help the radiologist identify and characterize iatrogenic injury rapidly at computed tomography (CT) imaging. Furthermore, selective use of intravenous or oral CT contrast material can help reveal injury and triage clinical management.
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http://dx.doi.org/10.1016/j.rcl.2014.05.011DOI Listing
September 2014

Clinical utility of endorectal MRI-guided prostate biopsy: preliminary experience.

J Magn Reson Imaging 2014 Aug 31;40(2):314-23. Epub 2013 Oct 31.

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

Purpose: To investigate the potential clinical utility of endorectal MRI-guided biopsy in patients with known or suspected prostate cancer.

Materials And Methods: We prospectively recruited 24 men with known or suspected prostate cancer in whom MRI-guided biopsy was clinically requested after multiparametric endorectal MRI showed one or more appropriate targets. One to six 18-gauge biopsy cores were obtained from each patient. Transrectal ultrasound guided biopsy results and post MRI-guided biopsy complications were also recorded.

Results: MRI-guided biopsy was positive in 5 of 7 patients with suspected prostate cancer (including 2 of 4 with prior negative ultrasound-guided biopsies), in 8 of 12 with known untreated prostate cancer (including 5 where MRI-guided biopsy demonstrated a higher Gleason score than ultrasound guided biopsy results), and in 3 of 5 with treated cancer. MRI-guided biopsies had a significantly higher maximum percentage of cancer in positive cores when compared with ultrasound guided biopsy (mean of 37 ± 8% versus 13 ± 4%; P = 0.01). No serious postbiopsy complications occurred.

Conclusion: Our preliminary experience suggests endorectal MRI-guided biopsy may safely contribute to the management of patients with known or suspected prostate cancer by making a new diagnosis of malignancy, upgrading previously diagnosed disease, or diagnosing local recurrence.
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http://dx.doi.org/10.1002/jmri.24383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4059791PMC
August 2014

Radiation-induced liver disease as a mimic of liver metastases at serial PET/CT during neoadjuvant chemoradiation of distal esophageal cancer.

Abdom Imaging 2014 Oct;39(5):963-8

Departments of Diagnostic Radiology (MJG, RAD, JSS, DDB, FVC), Surgery (JGH) and Radiation Oncology (CRT), Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR, 97239, USA.

Purpose: To determine the frequency and appearance of radiation-induced liver disease on PET/CT in patients undergoing serial imaging during neoadjuvant chemoradiation of distal esophageal cancer.

Materials And Methods: In this IRB-approved, HIPAA-compliant retrospective analysis, we identified 112 patients with distal esophageal cancer treated by neoadjuvant chemoradiation who had serial PET/CT imaging available for review. Two readers reviewed all studies in consensus and recorded those cases where new foci of visually detectable increased FDG avidity appeared in the liver during therapy. The etiology of such foci was determined from corresponding findings at CT or MRI, by hepatic biopsy during surgery, by characteristic evolution on post-operative imaging, or by a combination of these methods.

Results: New foci of FDG avidity developed in the liver during neoadjuvant therapy in 10 of 112 (9%) patients, of whom nine (8%) were determined to have radiation-induced liver disease based on further imaging and/or biopsy and one of whom had developed interval metastatic disease based on biopsy. In the cases of radiation-induced liver disease, the abnormal foci were found only in the caudate and left hepatic lobes, near the primary tumor, while the patient who developed interval metastatic disease had involvement of the inferior right hepatic lobe, remote from the radiation therapy field.

Conclusion: New foci of increased FDG avidity are commonly seen in the caudate and left hepatic lobes of the liver during neoadjuvant chemoradiation of distal esophageal cancer, and these findings generally reflect radiation-induced liver disease rather than metastatic disease.
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http://dx.doi.org/10.1007/s00261-014-0125-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4169728PMC
October 2014
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