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Multiparametric MRI (mpMRI), interpreted using PI-RADS, improves the initial detection of clinically significant prostate cancer. Prostate MR image quality has increasingly recognized relevance to the use of mpMRI for prostate cancer diagnosis. Additionally, mpMRI is increasingly used in scenarios beyond initial detection, including active surveillance and assessment for local recurrence after prostatectomy, radiation therapy, or focal therapy. In acknowledgment of these evolving demands, specialized prostate MRI scoring systems beyond PI-RADS have emerged to address distinct scenarios and unmet needs. Examples include Prostate Imaging Quality (PIQUAL) for assessment of image quality of mpMRI, Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) recommendations for evaluation of serial mpMRI examinations during active surveillance, Prostate Imaging for Recurrence Reporting (PI-RR) system for assessment for local recurrence after prostatectomy or radiation therapy, and Prostate Imaging after Focal Ablation (PI-FAB) for assessment for local recurrence after focal therapy. These systems' development and early uptake signal a compelling shift toward prostate MRI standardization in different scenarios, and ongoing research will help refine their roles in practice. This AJR Expert Panel Narrative Review critically examines these new prostate MRI scoring systems (PI-QUAL, PRECISE, PI-RR, and PI-FAB), analyzing the available evidence, delineating current limitations, and proposing solutions for improvement.

Prostate MRI has traditionally relied on qualitative interpretation. However, quantitative components hold the potential to markedly improve performance. The ADC from DWI is probably the most widely recognized quantitative MRI biomarker and has shown strong discriminatory value for clinically significant prostate cancer (csPCa) as well as for recurrent cancer after treatment. Advanced diffusion techniques, including intravoxel incoherent motion, diffusion kurtosis, diffusion tensor imaging, and specific implementations such as restriction spectrum imaging, purport even better discrimination, but are more technically challenging. The inherent T1 and T2 of tissue also provide diagnostic value, with more advanced techniques deriving luminal water imaging and hybrid-multidimensional MRI. Dynamic contrast-enhanced imaging, primarily using a modified Tofts model, also shows independent discriminatory value. Finally, quantitative size and shape features can be combined with the aforementioned techniques and be further refined using radiomics, texture analysis, and artificial intelligence. Which technique will ultimately find widespread clinical use will depend on validation across a myriad of platforms use-cases.

Objective: The purpose of this study was to investigate whether retroperitoneal craniocaudal nodal length or nodal volume predicts relapse risk in stage I testicular cancer., Materials and Methods: We retrospectively reviewed 826 testicular cancer patients. Of these 826 patients, 118 had stage I disease and either less than 2 years of surveillance or retroperitoneal lymph node dissection with no adjuvant chemotherapy. These patients formed our analytic cohort, and 3D nodal volumes and craniocaudal nodal length were measured. Association between relapse risk and craniocaudal nodal length and nodal volume was evaluated using univariable or multivariable logistic regression models adjusted for known prognostic factors., Results: Sixty-six (56%) of 118 patients had nonseminomatous germ cell tumor and 52 (44%) had seminomatous germ cell tumor. Craniocaudal nodal length proved to be an independent risk factor in nonseminomatous germ cell tumors using a multivariable logistic regression model adjusting for other potential known risk factors of embryonal predominance and lymphovascular invasion. For every 3-mm increase in craniocaudal nodal length, the risk of relapse increased by 52% (odds ratio [OR], 1.52; 95% CI, 1.03-2.25). For patients with seminomas, only primary tumor size was an independent risk factor for relapse (1.34, 1.02-1.75)., Conclusion: In nonseminomatous germ cell tumors, craniocaudal nodal length was shown to be associated with increased risk of relapse independently of other known risk factors. If validated in an independent cohort, craniocaudal nodal length could provide important additional information to inform management decisions in these patients.

OBJECTIVE. The purpose of this article is to evaluate the cost effectiveness of a treatment strategy for symptomatic uterine fibroids that uses MRI-guided focused ultrasound as a first-line therapy relative to uterine artery embolization (UAE) or hysterectomy. MATERIALS AND METHODS. We developed a decision-analytic model to compare the cost effectiveness of three first-line treatment strategies: MRI-guided focused ultrasound, UAE, and hysterectomy. Treatment-specific short- and long-term utilities, lifetime costs, and quality-adjusted life years (QALYs) were incorporated, allowing us to conduct an incremental cost-effectiveness analysis, using a societal willingness-to-pay (WTP) threshold of $50,000/QALY to designate a strategy as cost effective. Sensitivity analyses were subsequently performed on all key parameters. RESULTS. In the base-case analysis, UAE as a first-line treatment of symptomatic fibroids was the most effective and expensive strategy (22.75 QALYs; $22,968), followed by MRI-guided focused ultrasound (22.73 QALYs; $20,252) and hysterectomy (22.54 QALYs; $11,253). MRI-guided focused ultrasound was cost effective relative to hysterectomy, with an associated incremental cost-effectiveness ratio (ICER) of $47,891/QALY. The ICER of UAE relative to MRI-guided focused ultrasound was $234,565/QALY, exceeding the WTP threshold of $50,000/QALY, therefore rendering MRI-guided focused ultrasound also cost effective relative to UAE. In sensitivity analyses, results were robust to changes in most parameters but were sensitive to changes in probabilities of recurrence, symptom relief, and quality-of-life measures. CONCLUSION. First-line treatment of eligible women with MRI-guided focused ultra-sound is a cost-effective noninvasive strategy. For those not eligible for MRI-guided focused ultra-sound, UAE remains a cost-effective option. These recommendations integrate both the short- and long-term decrements in quality of life associated with the specific treatment modalities.

Objective: The purpose of this study was to evaluate the metastatic pattern of muscle-invasive bladder cancer and to correlate the findings with the characteristics of the primary tumor., Materials and Methods: From a clinic population of 392 patients with muscle-invasive (pT2-4) bladder cancer seen at our institution from January 2004 through December 2009, we studied the cases of 150 consecutively registered patients with pathologically proven metastatic disease. The metastasis-free intervals and metastatic patterns of different T categories were compared by Kruskal-Wallis test and Freeman-Halton extension of Fisher's exact test. Patients were divided into two histologic categories, those with transitional cell carcinoma and those with atypical histologic features. The metastasis-free interval and metastatic pattern of these two groups were compared by Mann-Whitney test and Fisher's exact test., Results: The study group consisted of 150 patients (116 men [77%], 34 women [23%]; median age, 64 years). The transitional cell carcinoma group consisted of 94 (63%) patients and the atypical histologic features group of 56 (37%) patients. The most common metastatic sites were lymph nodes (104 patients, 69%), bone (71 patients, 47%), lung (55 patients, 37%), liver (39 patients, 26%), and peritoneum (24 patients, 16%). Patients with tumors of a more advanced T category had shorter metastasis-free intervals (p = 0.001, df = 2). There was no significant difference in the metastatic patterns of tumors in the different T categories. Patients with atypical histologic features had a shorter median metastasis-free interval (3 months; range, 0-29 months) than patients with transitional cell carcinoma (12 months; range, 0-192 months) (p = 0.0001). Patients with atypical histologic features had a significantly higher incidence of peritoneal metastasis (p < 0.0002)., Conclusion: Lymph nodes, bones, lung, liver, and peritoneum are the most common sites of metastasis from bladder cancer. Tumors in a more advanced T category and those with atypical histologic features metastasize earlier. Tumors with atypical histologic features also have a higher frequency of peritoneal metastasis.

Objective: We evaluated the prevalence and significance of hepatic capsular retraction in hepatic metastases from breast cancer and correlated these with metastatic number, size, change in size over time, breast tumor histopathology, chemotherapeutic regimen, and tumor-receptor status., Materials and Methods: Abdominal CT scans of 200 consecutive women with breast carcinoma (mean age, 57 years; range, 33-81 years), obtained over a 7-month period, were retrospectively reviewed. Fifty-eight women had hepatic metastases. Two hundred seventy-two CT scans, including present and prior examinations (mean [+/- SD], 4.6 +/- 2 per patient), were evaluated. The number and diameter of liver metastases at all examinations, chemotherapeutic agents used, histopathologic diagnosis of breast tumor, and tumor-receptor status were compared in patients with and without capsular retraction. Descriptive analyses of the variables and comparisons of means and proportions as well as correlations were conducted., Results: Hepatic capsular retraction was observed in 29 patients with hepatic metastases (50%). Retraction ranged from 1 to 10 mm in depth. Patients with capsular retraction had significantly larger metastases than those without retraction (p < 0.05). The associations between retraction and increase in size of the subjacent metastasis and between retraction and decrease in size were statistically significant (p < 0.05). Capsular retraction was independent of the number of hepatic metastases, histopathologic diagnosis, tumor-receptor status, and chemotherapeutic regimen., Conclusion: Hepatic capsular retraction is common in patients with hepatic metastases from breast cancer and is associated with larger metastases and both increase and decrease in subjacent lesion size. It is unrelated to lesion number, histopathology, receptor status, or chemotherapeutic regimen.