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As more people receive coronavirus disease 2019 (COVID-19) vaccinations, the side effects of the vaccines will become more apparent. One reported side effect that has come to light is unilateral axillary lymphadenopathy ipsilateral to the vaccination site. In general, unilateral axillary lymphadenopathy has a broad differential including malignancy, infection, autoimmune disorder, and iatrogenic etiologies. We present a case of a previously healthy 38-year-old woman who received her first dose of Pfizer COVID-19 vaccination 3 days prior to presenting to the emergency department complaining of 2 weeks of abdominal pain and 20-pound unintentional weight loss. Unilateral axillary lymphadenopathy, ipsilateral to the vaccination site, was found on a contrast-enhanced computed tomography examination of the chest, abdomen, and pelvis. Subsequent diagnostic mammograms did not demonstrate evidence of malignancy; however, axillary ultrasound again revealed nonspecific lymphadenopathy. A short-term follow-up axillary ultrasound was recommended, rather than a lymph node biopsy, given the history of recent vaccination. At clinical follow-up, the patient's abdominal pain resolved and no further weight loss was noted. This case report discusses the key components and workup recommendation of unilateral axillary lymphadenopathy in the setting of COVID-19 vaccination., (© 2021 The Authors.)

Rationale and Objectives: Peer learning is a case-based group-learning model intended to improve performance. In this descriptive paper, we describe multi-institutional, multi-subspecialty, web-based radiology case conferences and summarize the participants' experiences., Materials and Methods: A semi-structured, 27-question survey was administered to radiologists participating in abdominal, cardiothoracic, and musculoskeletal case conferences. Survey questions included demographics, perceived educational value and challenges experienced. Survey question formats were continuous, binary, five-point Likert scale or text-based. The measures of central tendencies, proportions of responses and patterns were tabulated., Results: From 57 responders, 12/57 (21.1%) were abdominal, 16/57 (28.1%) were cardiothoracic, and 29/57 (50.8%) were musculoskeletal conference participants; 50/56 (89.3%) represented academic practice. Median age was 45 years (range 35-74); 43/57 (75.4%) were male. Geographically, 16/52 (30.8%) of participants were from the East Coast, 16/52 (30.8%) Midwest, 18/52 (34.6%) West Coast, and 2/52 (3.8%) International. The median reported educational value was 5/5 (interquartile range 5-5). Benefits of the case conference included education (50/95, 52.6%) and networking (39/95, 41.1%). Participants reported presenting the following cases: "great call" 32/48 (66.7%), learning opportunity 32/48 (66.7%), new knowledge 41/49 (83.7%), "zebras" 46/49 (93.9%), and procedural-based 16/46 (34.8%). All 51/51 (100%) of responders reportedly gained new knowledge, 49/51 (96.1%) became more open to group discussion, 34/51 (66.7%) changed search patterns, and 50/51 (98%) would continue to participate. Reported challenges included time zone differences and support from departments for a protected time to participate., Conclusion: Peer learning through multi-institutional case conferences provides educational and networking opportunities. Current challenges and desires include having department-supported protected time and ability to receive continuing medical education credit., (Copyright © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

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 Online supplemental material is available for this article. See also the editorial by Milot in this issue.

Value in medicine is defined as the ratio of quality and service and health care outcomes to the costs and inefficiencies of providing care. Creating patient-centered value in radiology reporting requires radiologists to provide accurate diagnostic interpretations in an accessible format with useful advice on further imaging, as well as report-embedded reference materials desired by the referring provider. The value- and service-centered radiologist provides urgent communications when appropriate and is readily available for report consultations. Indirect costs or inefficiencies embedded in report style can erode value. Value is preserved when radiologists strive for concise, clear, and timely reporting. © RSNA, 2018.

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., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Systematic transrectal ultrasonography (US)-guided biopsy is the standard approach for histopathologic diagnosis of prostate cancer. However, this technique has multiple limitations because of its inability to accurately visualize and target prostate lesions. Multiparametric magnetic resonance (MR) imaging of the prostate is more reliably able to localize significant prostate cancer. Targeted prostate biopsy by using MR imaging may thus help to reduce false-negative results and improve risk assessment. Several commercial devices are now available for targeted prostate biopsy, including in-gantry MR imaging-targeted biopsy and real-time transrectal US-MR imaging fusion biopsy systems. This article reviews the current status of MR imaging-targeted biopsy platforms, including technical considerations, as well as advantages and challenges of each technique. © RSNA, 2017.

Purpose To determine if adrenal calcifications seen at computed tomography (CT) are associated with familial cerebral cavernous malformations (fCCMs) in carriers of the CCM1 Common Hispanic Mutation. Materials and Methods This study was approved by the institutional review board. The authors retrospectively reviewed abdominal CT scans in 38 patients with fCCM, 38 unaffected age- and sex-matched control subjects, and 13 patients with sporadic, nonfamilial cerebral cavernous malformation (CCM). The size, number, and laterality of calcifications and the morphologic characteristics of the adrenal gland were recorded. Brain lesion count was recorded from brain magnetic resonance (MR) imaging in patients with fCCM. The prevalence of adrenal calcifications in patients with fCCM was compared with that in unaffected control subjects and those with sporadic CCM by using the Fisher exact test. Additional analyses were performed to determine whether age and brain lesion count were associated with adrenal findings in patients with fCCM. Results Small focal calcifications (SFCs) (≤5 mm) were seen in one or both adrenal glands in 19 of the 38 patients with fCCM (50%), compared with 0 of the 38 unaffected control subjects (P < .001) and 0 of the 13 subjects with sporadic CCM (P = .001). Adrenal calcifications in patients with fCCM were more frequently left sided, with 17 of 19 patients having more SFCs in the left adrenal gland than the right adrenal gland and 50 of the 61 observed SFCs (82%) found in the left adrenal gland. No subjects had SFCs on the right side only. In patients with fCCM, the presence of SFCs showed a positive correlation with age (P < .001) and number of brain lesions (P < .001). Conclusion Adrenal calcifications identified on CT scans are common in patients with fCCM and may be a clinically silent manifestation of disease. © RSNA, 2017.

Purpose: To evaluate clinical and imaging features of pancreatic pseudocyst-portal vein fistula (PPVF)., Methods: Patients with evidence of PPVF on CT/MRI were included. Clinical presentation, outcomes, imaging appearance of the portal vein were recorded., Results: 75% of patients developed portal hypertension, 62% cavernous transformation of the portal vein and 25% portal biliopathy. PPVF presented on CT as fluid-attenuated portal vein, and on MRI as T2-weighted hyperintense fluid-filled portal vein. PPVF was misdiagnosed as portal vein thrombosis in all patients who underwent CT as initial examination., Conclusions: Whenever PPVF is suspected on CT, MRI can be helpful to achieve accurate diagnosis and avoid unnecessary interventions., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Although radical prostatectomy is a popular treatment modality for clinically localized prostate cancer, 10-year biochemical recurrence can reach 28%. Before salvage radiation therapy (SRT), prostate-specific antigen (PSA) values alone should be used cautiously in predicting SRT eligibility. A long, slow PSA rise may suggest locally confined disease still amenable to SRT; corresponding imaging to identify potential gross recurrence is useful. Patients with local disease may safely benefit from higher doses of radiation.

Purpose: After an initial negative biopsy there is an ongoing need for strategies to improve patient selection for repeat biopsy as well as the diagnostic yield from repeat biopsies., Materials and Methods: As a collaborative initiative of the AUA (American Urological Association) and SAR (Society of Abdominal Radiology) Prostate Cancer Disease Focused Panel, an expert panel of urologists and radiologists conducted a literature review and formed consensus statements regarding the role of prostate magnetic resonance imaging and magnetic resonance imaging targeted biopsy in patients with a negative biopsy, which are summarized in this review., Results: The panel recognizes that many options exist for men with a previously negative biopsy. If a biopsy is recommended, prostate magnetic resonance imaging and subsequent magnetic resonance imaging targeted cores appear to facilitate the detection of clinically significant disease over standardized repeat biopsy. Thus, when high quality prostate magnetic resonance imaging is available, it should be strongly considered for any patient with a prior negative biopsy who has persistent clinical suspicion for prostate cancer and who is under evaluation for a possible repeat biopsy. The decision of whether to perform magnetic resonance imaging in this setting must also take into account the results of any other biomarkers and the cost of the examination, as well as the availability of high quality prostate magnetic resonance imaging interpretation. If magnetic resonance imaging is done, it should be performed, interpreted and reported in accordance with PI-RADS version 2 (v2) guidelines. Experience of the reporting radiologist and biopsy operator are required to achieve optimal results and practices integrating prostate magnetic resonance imaging into patient care are advised to implement quality assurance programs to monitor targeted biopsy results., Conclusions: Patients receiving a PI-RADS assessment category of 3 to 5 warrant repeat biopsy with image guided targeting. While transrectal ultrasound guided magnetic resonance imaging fusion or in-bore magnetic resonance imaging targeting may be valuable for more reliable targeting, especially for lesions that are small or in difficult locations, in the absence of such targeting technologies cognitive (visual) targeting remains a reasonable approach in skilled hands. At least 2 targeted cores should be obtained from each magnetic resonance imaging defined target. Given the number of studies showing a proportion of missed clinically significant cancers by magnetic resonance imaging targeted cores, a case specific decision must be made whether to also perform concurrent systematic sampling. However, performing solely targeted biopsy should only be considered once quality assurance efforts have validated the performance of prostate magnetic resonance imaging interpretations with results consistent with the published literature. In patients with negative or low suspicion magnetic resonance imaging (PI-RADS assessment category of 1 or 2, respectively), other ancillary markers (ie PSA, PSAD, PSAV, PCA3, PHI, 4K) may be of value in identifying patients warranting repeat systematic biopsy, although further data are needed on this topic. If a repeat biopsy is deferred on the basis of magnetic resonance imaging findings, then continued clinical and laboratory followup is advised and consideration should be given to incorporating repeat magnetic resonance imaging in this diagnostic surveillance regimen., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Our aim was to demonstrate the imaging characteristics of epiploic appendages in native, acute inflamed/ischemic and post-infarcted states through retrospective imaging analysis, with clinical and pathologic correlation, and to discuss clinical implications. Cases were gathered mostly retrospectively and reviewed for inclusion based on established diagnostic criteria. Radiology report text search was used to find cases, using terms "epiploic," "appendage," "appendagitis," and "peritoneal body." Data records included patient demographics, relevant clinical data, lesion size, location and apparent imaging composition, and the presence of change or stability in features over multiple studies. Pathologic and clinical data were sought and assessed for correlation. Imaging studies of 198 individuals were included (mean age 50, range 9-95), with a total of 228 lesions: 63 acute and 165 non-acute presentations. All included subjects had CT imaging and some had lesions visible on radiographs, MRI, PET/CT, and sonography. 23 subjects had more than one studied lesion. In addition to classic acute appendagitis, more frequently encountered are post-infarcted appendages either in situ along the colon, adhered to peritoneal or serosal surfaces, or freely mobile in the peritoneum as loose bodies. The majority of the non-acute varieties are recognizable due to peripheral calcification that develops over time following ischemic insult. Multiple cases demonstrated the imaging natural history and confirmed pathologic basis for imaging findings. In summary, acute and post-infarcted epiploic appendages have characteristic imaging appearances and natural history which should provide correct diagnosis in most cases. Incidental post-infarcted epiploica are more commonly encountered than acute presentations.

OBJECTIVE. In this article, we summarize the progress to date on the use of superparamagnetic iron oxide nanoparticles (SPIONs) as contrast agents for MRI of inflammatory processes. CONCLUSION. Phagocytosis by macrophages of injected SPIONs results in a prolonged shortening of both T2 and T2* leading to hypointensity of macrophage-infiltrated tissues in contrast-enhanced MR images. SPIONs as contrast agents are therefore useful for the in vivo MRI detection of macrophage infiltration, and there is substantial research and clinical interest in the use of SPION-based contrast agents for MRI of infection and inflammation. This technique has been used to identify active infection in patients with septic arthritis and osteomyelitis; importantly, the MRI signal intensity of the tissue has been found to return to its unenhanced value on successful treatment of the infection. In SPION contrast-enhanced MRI of vascular inflammation, animal studies have shown decreased macrophage uptake in atherosclerotic plaques after treatment with statin drugs. Human studies have shown that both coronary and carotid plaques that take up SPIONs are more prone to rupture and that abdominal aneurysms with increased SPION uptake are more likely to grow. Studies of patients with multiple sclerosis suggest that MRI using SPIONs may have increased sensitivity over gadolinium for plaque detection. Finally, SPIONs have enabled the tracking and imaging of transplanted stem cells in a recipient host.

Imaging plays a role in the management of patients with acute kidney injury or chronic kidney disease. However, clinical circumstances strongly impact the appropriateness of imaging use. In patients with newly detected renal dysfunction, ultrasonography can assess for reversible causes, assess renal size and echogenicity, and thus, establish the chronicity of disease. Urinary obstruction can be detected, but imaging is most useful in high-risk groups or in patients in whom there is a strong clinical suspicion for obstruction. Computed tomography, computed tomography or magnetic resonance arteriography, and percutaneous ultrasound-guided renal biopsy are valuable in other clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Multiparametric MRI has developed as a tool for prostate cancer lesion detection, characterization, staging, surveillance, and imaging of local recurrence. Given the disease frequency and the growing importance of imaging, as reliance on PSA declines, radiologists involved in prostate MRI imaging must become proficient with the fundamentals of multiparametric prostate MRI (T2WI, DWI, DCE-MRI, and MR spectroscopy). Interpretation and reporting must yield accuracy, consistency, and add value to clinical care. This review provides a primer to novices and trainees learning about multiparametric prostate MRI. MRI technique is presented along with the use of particular MRI sequences. Relevant prostate anatomy is outlined and imaging features of prostate cancer with staging are discussed. Finally structured reporting is introduced, and some limitations of prostate MRI are discussed.

As the incidence of cancer continues to increase, imaging will play an ever more important role in the detection, diagnosis, staging, surveillance, and therapeutic monitoring of cancer. Diagnostic errors in the initial discovery of cancer or at follow-up assessments can lead to missed opportunities for curative treatments or altering or reinitiating therapies, as well as adversely impact clinical trials. Radiologists must have an understanding of cancer biology, treatments, and imaging appearance of therapeutic effects and be mindful that metastatic disease can involve virtually any organ system. Knowledge of patient history and tumor biology allows for optimizing imaging protocols. The majority of cancer imaging utilizes computed tomography, where contrast enhancement characteristics of lesions can be exploited and detection of subtle lesions can involve manipulation of window width and level settings, multiplanar reconstruction, and maximum intensity projections. For magnetic resonance imaging, diffusion-weighted imaging can render lesions more conspicuous, improve characterization, and help assess therapeutic response. Positron emission tomography with (18)F-labeled fluorodeoxyglucose and sodium fluoride are invaluable in detecting occult existing and new cancerous lesions, characterizing indeterminate lesions, and assessing treatment effects. The most common anatomic "hiding places" for cancer include metastases to solid organs, such as the kidneys and pancreas, gastrointestinal tract, peritoneum and retroperitoneum, neural axis, muscular body wall, and bones. Consistent work habits, employment of appropriate technologies, and particular attention to the above anatomic areas can enhance detection, staging, and reassessments of these complex and often stealthy diseases, ensuring the radiologists' integral role in the cancer care team.

Prostate cancer is the most common noncutaneous male malignancy in the United States. The use of serum prostate-specific antigen as a screening tool is complicated by a significant fraction of nonlethal cancers diagnosed by biopsy. Ultrasound is used predominately as a biopsy guidance tool. Combined rectal examination, prostate-specific antigen testing, and histology from ultrasound-guided biopsy provide risk stratification for locally advanced and metastatic disease. Imaging in low-risk patients is unlikely to guide management for patients electing up-front treatment. MRI, CT, and bone scans are appropriate in intermediate-risk to high-risk patients to better assess the extent of disease, guide therapy decisions, and predict outcomes. MRI (particularly with an endorectal coil and multiparametric functional imaging) provides the best imaging for cancer detection and staging. There may be a role for prostate MRI in the context of active surveillance for low-risk patients and in cancer detection for undiagnosed clinically suspected cancer after negative biopsy results. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Entrapped soft tissues such as periosteum and tendons have been described within joints and physeal fractures in the literature and frequently result in irreducible fractures and posttraumatic growth disturbances. We believe this case represents a novel presentation of acute, preoperative, magnetic resonance (MR) imaging diagnosis of a torn medial collateral ligament entrapped within a proximal tibial physeal separation. This case is presented with MR imaging and operative correlation of the findings.

Objective: The objective of the study was to determine incontinence pessaries' mechanism of action by measuring changes on urodynamic studies (UDS) and dynamic magnetic resonance imaging (MRI) with and without pessaries in place., Study Design: Women with stress incontinence had UDS and MRI performed with and without incontinence dish pessaries., Results: Fifteen women were evaluated. Pessary insertion resulted in increased urethral resistance; detrusor pressures increased (33-45 cm H(2)O) and maximal flow rates decreased (30 to 19 mL/second). With Valsalva on MRI, pessaries were associated with decreased posterior urethrovesical angles (175-130 degrees), bladder neck elevation (0.3 below to 0 .8 cm above the pubococcygeal line) and increased urethral lengths (2.4 to 2.97 cm). Bladder neck funneling with cough occurred in 14 patients without pessaries and 3 with pessaries., Conclusion: On UDS and MRI following pessary placement, continence restoration was associated with decreased posterior urethrovesical angles, bladder neck descent and funneling, and increased urethral lengths and resistance to urine flow.

The major goal for prostate cancer imaging in the next decade is more accurate disease characterization through the synthesis of anatomic, functional, and molecular imaging information. No consensus exists regarding the use of imaging for evaluating primary prostate cancers. Ultrasonography is mainly used for biopsy guidance and brachytherapy seed placement. Endorectal magnetic resonance (MR) imaging is helpful for evaluating local tumor extent, and MR spectroscopic imaging can improve this evaluation while providing information about tumor aggressiveness. MR imaging with superparamagnetic nanoparticles has high sensitivity and specificity in depicting lymph node metastases, but guidelines have not yet been developed for its use, which remains restricted to the research setting. Computed tomography (CT) is reserved for the evaluation of advanced disease. The use of combined positron emission tomography/CT is limited in the assessment of primary disease but is gaining acceptance in prostate cancer treatment follow-up. Evidence-based guidelines for the use of imaging in assessing the risk of distant spread of prostate cancer are available. Radionuclide bone scanning and CT supplement clinical and biochemical evaluation (prostate-specific antigen [PSA], prostatic acid phosphate) for suspected metastasis to bones and lymph nodes. Guidelines for the use of bone scanning (in patients with PSA level > 10 ng/mL) and CT (in patients with PSA level > 20 ng/mL) have been published and are in clinical use. Nevertheless, changes in practice patterns have been slow. This review presents a multidisciplinary perspective on the optimal role of modern imaging in prostate cancer detection, staging, treatment planning, and follow-up.

Desmoplastic fibroma of bone is a rare tumor demonstrating the same histologic and biologic features of its soft tissue counterpart, aggressive fibromatosis. We report the second case of desmoplastic fibroma of bone with extensive chondroid metaplasia. The tumor arose in the left ischium of a 51-year-old male, with extension into adjacent musculature as a pseudoencapsulated mass. The infiltrating growth and quality of the fibrous component are characteristic of desmoplastic fibroma, and in addition, abrupt transitions into bland hyalin cartilage were frequent. Discriminating features of this lesion from other bone tumors capable of biphasic expression of fibrous and chondroid elements are discussed.

Objective: The objectives of our study were to evaluate the accuracy of combined endorectal and phased-array MRI in detecting pelvic lymph node metastasis (LNM) in patients with prostate cancer and to determine whether radiologists' predictions of LNM improve with the incorporation of Partin nomogram or MRI findings (or both) regarding extracapsular extension or seminal vesicle invasion., Subjects and Methods: Between May 1999 and September 2003, 411 consecutive patients with clinically localized prostate cancer underwent MRI before surgery. Serum prostate-specific antigen (PSA) level, Gleason grade, clinical stage, greatest percentage of cancer and percentage of positive cores in all biopsy cores, presence of perineural invasion on biopsy, and likelihood of LNM based on the Partin tables (2001 version) were recorded. MRI studies were interpreted prospectively, but the risks of LNM, extracapsular extension, and seminal vesicle invasion were scored retrospectively on the basis of the MRI reports. Surgical pathology constituted the standard of reference. The accuracy of LNM prediction was assessed using areas under receiver operating characteristic curves (AUCs) and univariate and multivariate logistic regression analyses. For multivariate models, the jackknife method was used for bias correction. A p value below 0.05 denoted statistical significance., Results: At surgical pathology, LNM was present in 22 (5%) of 411 patients. MRI was an independent statistically significant predictor of LNM (p = 0.002), with positive and negative predictive values of 50% and 96.36%, respectively. On multivariate analysis, prediction of lymph node status using the model that included all MRI variables (extracapsular extension, seminal vesicle invasion, and LNM) along with the Partin nomogram results had a significantly greater AUC than the univariate model that included only MRI LNM findings (AUC = 0.892 vs 0.633, respectively; p < 0.01)., Conclusion: Incorporation of the Partin nomogram results and MRI findings regarding both extracapsular extension and seminal vesicle invasion improves the MR prediction of LNM in patients with prostate cancer.

Purpose: To evaluate retrospectively the accuracy of endorectal magnetic resonance (MR) imaging for the depiction of tumor, extracapsular extension (ECE), and seminal vesicle invasion (SVI) before salvage prostatectomy in patients with locally recurrent prostate cancer after radiation therapy, by using pathologic analysis as the reference standard., Materials and Methods: The Institutional Review Board granted exempt status for this HIPAA-compliant study, with a waiver of informed consent. Forty-five consecutive patients (age range, 43-76 years) were identified who underwent salvage radical prostatectomy for prostate cancer at Memorial Sloan-Kettering Cancer Center between December 1, 1998, and October 31, 2004, and who underwent endorectal MR imaging prior to surgery. Tumor localization and determination of local stage with MR imaging were performed independently by two radiologists. Interpretations were compared to pathologic findings from surgical specimens. Interrater variability was estimated with the kappa statistic. Areas under the receiver operating characteristic curve (AUCs) were used to assess the accuracy of endorectal MR imaging in tumor detection and determination of ECE and SVI., Results: Findings of histologic examination showed that tumor was present in all patients. For tumor detection, the AUC value for reader 1 was 0.75 (95% confidence interval [CI]: 0.67, 0.84), whereas the AUC value for reader 2 was 0.61 (95% CI: 0.52, 0.71). The AUC values for prediction of ECE were 0.87 (95% CI: 0.80, 0.94) for reader 1 and 0.76 (95% CI: 0.67, 0.85) for reader 2. The AUC values for prediction of SVI were 0.76 (95% CI: 0.62, 0.90) for reader 1 and 0.70 (95% CI: 0.56, 0.85) for reader 2. For all variables, the kappa statistics used to assess interrater agreement between readers were fair (0.45, 0.52, and 0.47 for tumor location, ECE, and SVI, respectively)., Conclusion: Endorectal MR imaging following radiation therapy can help identify tumor sites and depict ECE and SVI with reasonable accuracy in patients with recurrent prostate cancer., (RSNA, 2006.)

Purpose: To assess the incremental value of endorectal magnetic resonance (MR) imaging findings in addition to clinical variables for prediction of extracapsular extension (ECE) in patients with prostate cancer., Materials and Methods: In this cohort study, 344 consecutive patients with biopsy-proved prostate cancer underwent endorectal MR imaging prior to surgery; 216 of these patients also underwent MR spectroscopic imaging. MR images were interpreted by 10 attending radiologists. The likelihood of ECE was scored retrospectively on the basis of MR imaging reports. Clinical variables included serum prostate-specific antigen (PSA) level, Gleason score, clinical stage of tumor, greatest percentage of cancer in all core biopsy specimens, percentage of cancer-positive core specimens in all core biopsy specimens, and presence of perineural invasion. For data analysis, receiver operating characteristic (ROC) curves and univariate and multivariate logistic regression analyses were used. Jackknife analysis was used for prediction of probability from a model that included clinical variables as tested comparatively with a model that included the clinical variables plus endorectal MR imaging findings. A difference with P <.05 was considered significant., Results: At univariate analysis, all variables were associated with ECE. At ROC univariate analysis, endorectal MR imaging findings had the largest area under the ROC curve. At multivariate analysis, serum PSA level, percentage of cancer in all core biopsy specimens, and endorectal MR imaging findings (P =.001, P =.001, and P <.001, respectively) were predictors of ECE. Areas under ROC curve for two models, with and without endorectal MR imaging findings, were 0.838 and 0.772, respectively (P =.022)., Conclusion: A model containing endorectal MR imaging findings has a significantly larger area under the ROC curve than a model containing only clinical variables; thus, endorectal MR imaging findings add incremental value in the prediction of ECE., (Copyright RSNA, 2004)

Purpose: To determine whether chronic prostatitis affects three-dimensional proton magnetic resonance (MR) spectroscopic imaging in evaluation of disease in the peripheral zone., Materials and Methods: Combined MR imaging and three-dimensional MR spectroscopic imaging data were examined retrospectively in 12 patients with radical prostatectomy specimens that contained regions of chronic prostatitis larger than 6 mm in the peripheral zone. The 6-mm restriction was based on MR spectroscopic imaging spatial resolution of 6.25 mm. Transverse T2-weighted MR images were reviewed for changes in signal intensity (SI): normal, suspicious for cancer (nodular focal low SI), or indeterminate (focal low SI that was not nodular or contour deforming or diffuse low SI). At MR spectroscopic imaging, proton spectra were considered suspicious for cancer if the ratio of choline plus creatine to citrate was more than 2 SDs above normal mean peripheral zone values., Results: In the 12 patients, mean pretreatment prostate-specific antigen level was 5.77 +/- 2.07 (SD), and median biopsy Gleason score for the gland was 6. At MR imaging in the area of histopathologically confirmed chronic prostatitis, seven of 12 patients had focal low SI that was not nodular (contour deforming) over a region in and around the pathologically defined focus of chronic prostatitis. MR imaging in one patient showed diffuse low SI that correlated with a diffuse area of chronic prostatitis at pathologic examination. MR imaging in another patient showed nodular focal low SI that was suspicious for cancer and corresponded to a focus of chronic prostatitis at pathologic examination. The remaining three patients had no MR imaging abnormality in the region of chronic prostatitis. In the pathologically identified regions of chronic prostatitis, MR spectroscopic imaging data in nine of 12 patients demonstrated elevated choline peak and reduced or no citrate, findings that mimic those of cancer. In two patients, the spectra were normal, and in the remaining patient, the spectra were nondiagnostic., Conclusion: At MR spectroscopic imaging, pathologically confirmed chronic prostatitis may demonstrate metabolic abnormality that leads to false-positive diagnosis of cancer. The most common MR imaging finding in chronic prostatitis was focal low SI that was not specific for cancer. In one patient, the MR imaging diagnosis of cancer could not be excluded., (Copyright RSNA, 2004)

Imaging prostate cancer continues to represent a clinical challenge for both primary and recurrent disease. In the evaluation of the persistent/recurrent/metastatic prostate cancer, knowledge of cancer location (local v distant), size, and extent are essential in order to design a treatment, tailored to each patient's needs. There are evidence-based guidelines for the use of imaging in assessing the presence of distant spread of prostate cancer. Radionuclide bone scans and computed tomography (CT), magnetic resonance imaging (MRI), and/or positron emission tomography (PET) supplement clinical and biochemical evaluations (prostate-specific antigen [PSA]) for suspected metastatic disease to bones and lymph nodes. There is no consensus about the use of imaging in the evaluation of local tumor recurrence. The use of ultrasound has been limited to biopsy guidance of the prostatic bed, or percutaneous biopsy of enlarged lymph nodes detected on CT or MRI. The use of MRI is evolving. Recent studies indicate that the use of MRI provides valuable information in the evaluation of local tumor recurrence, and nodal and bony metastases. In a patient post-radiation therapy, the method of combining MRI anatomic information with MR spectroscopic metabolic information is evolving. Another modality offering information about anatomy and metabolism of the local disease is PET/CT. The value of PET/CT at present is controversial, but new studies exploring the role of PET/CT in aggressive prostate cancer are promising.

Objective: To assess the performance of sonography in evaluating small indeterminate liver lesions detected on computed tomography in patients with cancer., Methods: Radiology database review from January 1, 1998, to August 4, 2000, identified 76 patients with 124 indeterminate hepatic lesions smaller than 1.5 cm on computed tomography who had abdominal sonography within 3 months. Sonographic reports and images were reviewed to assess whether lesions were referenced or specifically sought and to verify lesion correspondence, detection, and characterization. The validity of sonographic characterization was determined by histopathologic examination or follow-up imaging (mean time to follow up, 17 months; range, 6.5-38.8 months)., Results: Sixty (48%) of 124 indeterminate lesions were evident on sonography. Detection improved when lesions were specifically sought and lesion size was greater than 0.5 cm. Forty (66%) of 61 lesions were detected when the radiologist referenced the preceding computed tomography versus 20 (32%) of 63 lesions when the computed tomographic findings were not referenced (P = .0004). Fifty-one (67%) of 76 lesions measuring 0.6 to 1.5 cm were detected on sonography versus 9 (19%) of 48 lesions measuring 0.1 to 0.5 cm. Lesion size (P < .0001) and body habitus (P = .02) were significant factors influencing lesion detection. Sonography characterized 56 (93%) of 60 detected lesions (33 cysts, 18 solid lesions/metastases, and 5 hemangiomas). Sonographic diagnoses were supported in 42 (93%) of 45 lesions by follow-up imaging (37 of 40) or histopathologic examination (5 of 5)., Conclusions: Sonography may be useful in cancer patients with average body habitus to characterize small (0.6- to 1.5-cm) indeterminate liver lesions detected on computed tomography.