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INTRODUCTION AND OBJECTIVE:Magnetic resonance imaging (MRI) offers high spatial resolution imaging of the prostate. Diagnostic radiologists annotate and describe the location of lesions in the imag...

Objective To evaluate the use of 3D computed aided designs and 3D-printed models as pre-operative planning tools for urologists, in addition to radiologist interpreted mp-MRIS, prior to radical prostatectomy procedures. Methods Ten patients with biopsy-positive lesions detected on mp-MRI were retrospectively selected. Radiologists identified lesion locations using a Prostate Imaging-Reporting and Data System (PI-RADS) map and segmented the prostate, lesion(s), and surrounding anatomy to create 3D-CADs and 3D-printed models for each patient. 6 uro-oncologists randomly reviewed three modalities (mp-MRI, 3D-CAD, and 3D-printed models) for each patient and identified lesion locations which were graded for accuracy against the radiologists’ answers. Questionnaires assessed decision confidence, ease-of-interpretation, and usefulness for preoperative planning for each modality. Results Using 3D-CADs and 3D-printed models compared to mp-MRI, urologists were 2.4x and 2.8x more accurate at identifying the lesion(s), 2.7x and 3.2x faster, 1.6x and 1.63x more confident, and reported it was 1.6x and 1.7x easier to interpret. 3D-CADs and 3D-printed models were reported significantly more useful for overall pre-operative planning, identifying lesion location(s), determining degree of nerve sparing, obtaining negative margins, and patient counseling. Sub-analysis showed 3D-printed models demonstrated significant improvements in ease-of-interpretation, speed, usefulness for obtaining negative margins, and patient counseling compared to 3D-CADs. Conclusion 3D-CADs and 3D-printed models are useful adjuncts to mp-MRI in providing urologists with more practical, accurate, and efficient pre-operative planning.

Background Multiparametric magnetic resonance imaging (mpMRI) for prostate cancer detection without careful patient selection may lead to excessive resource utilization and costs. Objective To develop and validate a clinical tool for predicting the presence of high-risk lesions on mpMRI. Design, setting, and participants Four tertiary care centers were included in this retrospective and prospective study (BiRCH Study Collaborative). Statistical models were generated using 1269 biopsy-naive, prior negative biopsy, and active surveillance patients who underwent mpMRI. Using age, prostate-specific antigen, and prostate volume, a support vector machine model was developed for predicting the probability of harboring Prostate Imaging Reporting and Data System 4 or 5 lesions. The accuracy of future predictions was then prospectively assessed in 214 consecutive patients. Outcome measurements and statistical analysis Receiver operating characteristic, calibration, and decision curves were generated to assess model performance. Results and limitations For biopsy-naive and prior negative biopsy patients (n = 811), the area under the curve (AUC) was 0.730 on internal validation. Excellent calibration and high net clinical benefit were observed. On prospective external validation at two separate institutions (n = 88 and n = 126), the machine learning model discriminated with AUCs of 0.740 and 0.744, respectively. The final model was developed on the Microsoft Azure Machine Learning platform (birch.azurewebsites.net). This model requires a prostate volume measurement as input. Conclusions In patients who are naive to biopsy or those with a prior negative biopsy, BiRCH models can be used to select patients for mpMRI. Patient summary In this multicenter study, we developed and prospectively validated a calculator that can be used to predict prostate magnetic resonance imaging (MRI) results using patient age, prostate-specific antigen, and prostate volume as input. This tool can aid health care professionals and patients to make an informed decision regarding whether to get an MRI.

Introduction We assessed the institutional learning curve associated with adopting fusion biopsy using PI-RADS™ (Prostate Imaging-Reporting and Data System) Version 2 (v2) to detect clinically significant prostate cancer, defined as Gleason 7 or greater in men with prior negative biopsies, and identified patient and technical factors that predict success in detecting clinically significant prostate cancer. Methods A total of 113 consecutive patients with at least 1 prior negative biopsy and multiparametric magnetic resonance imaging examination of the prostate with a PI-RADS 3 or greater index lesion underwent fusion biopsy at a single academic center previously naive to fusion biopsy technology. Outcomes include detection rates for Gleason 6 cancer, clinically significant prostate cancer and any cancer. Multiple logistic regression with model selection was used to select covariates having significant effects on the outcome. Results Prostate cancer was identified in 52% of patients with prior negative prostate biopsies. Among the patients diagnosed with prostate cancer 80% had clinically significant cancer. The clinically significant prostate cancer detection rates using fusion biopsy when a PI-RADS 3, 4 or 5 index lesion was present on multiparametric magnetic resonance imaging were 6%, 46% and 66%, respectively. PI-RADS v2 score had a predictive accuracy (AUC) of 0.79 for clinically significant prostate cancer detection. Institutional experience over time, magnetic resonance imaging estimated prostate volume and PI-RADS v2 score were independent predictors of clinically significant prostate cancer using fusion biopsy. Conclusions Since fusion biopsy is a highly technique driven process, development of internal quality measures to assess the institutional learning curve and the quality of PI-RADS v2 scoring is critical with the adoption of this technology.

INTRODUCTION AND OBJECTIVES:The introduction of MR/US fusion biopsy has led to increased detection of clinically significant prostate cancer. Less certain are the concerns of prostate cancer oversa...

To assess clinicopathologic factors on MR/US fusion biopsy that might predict failure of theoretical selection criteria for prostatic hemigland ablation (HA).A retrospectively maintained single institution multiparametric MRI database (n = 1667) was queried to identify 355 patients who underwent MR/US fusion biopsy, including both targeted biopsy and concurrent systematic biopsy from December 1, 2014 to June 1, 2018. Clinical, pathological, and imaging variables were assessed on fusion biopsy (Table 1) to determine who met theoretical selection criteria for HA, defined as unilateral intermediate-risk prostate cancer per NCCN criteria (Grade Group [GG] 2 or 3 with prostate-specific antigen20) and no evidence of extraprostatic extension (EPE) on multiparametric MRI. Predictors of selection criteria failure were then assessed in patients who also underwent radical prostatectomy (RP). Failure of the theoretical HA selection criteria was defined as presence of GG ≧ 2 on the contralateral (untreated) side, or the presence of high-risk disease (any GG ≧ 4 or EPE) in the RP specimen.Of the 355 patients who underwent fusion biopsy, 84 patients met the theoretical selection criteria for HA. Of those patients eligible, 54 underwent RP, 37 (68.5%) of which represented unsuccessful HA selection criteria. Patients no longer met HA selection criteria on the basis of upgrading alone in 6/54 (11.1%), EPE alone in 9/54 (16.7%), bilateral GG 2 or 3 in 16/54 (29.6%) or combined EPE and bilateral GG 2 or 3 in 6/54 (11.1%) cases. In the HA selection failures due to upgrading, three also had EPE, one of whom also had missed contralateral GG ≧ 2 disease. The only factor independently associated with HA failure was any presence of cribriform pattern (HR 7.01, P = 0.021). Perineural invasion on systematic biopsyalso appeared to improve the performance of our multivariable model (HR 5.33, P = 0.052), though it was not statistically significant when using a cutoff of0.05. Accuracy for predicting successful HA was 0.32 and improved to 0.74 if PNI or cribriform were excluded and 0.84 if both were excluded.In a retrospective analysis of RP patients who underwent preoperative MRI/US fusion biopsy, current selection criteria for prostatic HA based on NCCN intermediate-risk stratification failed to accurately identify appropriate candidates in 68.5% of patients. Cribriform pattern and PNI detected on biopsy reduced the failure of hemigland selection criteria to 43%. These criteria should be routinely reported on biopsy pathology and taken into consideration when selecting patients for HA in prospective clinical trials.

Recently a large body of evidence has emerged indicating that cribriform morphology is an aggressive prostate cancer morphological pattern associated with higher cancer specific mortality. In a comprehensive analysis we compared traditional and contemporary prostate biopsy techniques to detect prostate cancer with cribriform morphology with radical prostatectomy serving as the reference standard.We queried a retrospectively maintained, single institution, multiparametric magnetic resonance imaging database of 1,001 patients to identify 240 who underwent magnetic resonance imaging-ultrasound fusion targeted biopsy and concurrent systematic biopsy from December 2014 to December 2016. Of the 3,978 biopsy cores obtained 694 positive cores were rereviewed by a genitourinary pathologist for pattern 4 subtype (cribriform, fused and poorly formed glands). Using paired analysis pathological results among 3 biopsy methods (systematic biopsy, targeted biopsy and systematic plus targeted biopsy) were compared. Prostatectomy specimens were also pathologically reviewed.Systematic plus targeted biopsy was superior to systematic biopsy alone or targeted biopsy alone to detect cribriform morphology (all p0.0001). On final histopathology cribriform tumor foci were associated with an increased percent of pattern 4 involvement and extraprostatic extension (p0.0001 and 0.003, respectively). Only 17.4% of cribriform tumors in pure form were visible on multiparametric magnetic resonance imaging. Based on final histopathology the sensitivity of systematic biopsy, targeted biopsy and systematic plus targeted biopsy for cribriform morphology was 20.7%, 28.6% and 37.1%, respectively.Although systematic plus targeted biopsy was the most accurate biopsy method to detect cribriform morphology, biopsy sensitivity and specificity remained poor.

Background The purpose of this study is to assess the institutional learning curve associated with adopting FB using PI-RADS Version 2 (v2) for detecting clinically significant prostate cancer (csPCa), defined as Gleason ≥ 7 in men with prior negative biopsies and to identify patient and technical factors that predict success at detecting csPCa. Methods A total of 113 consecutive patients with at least one prior negative biopsy and a multiparametric MRI (mpMRI) exam of the prostate with a PIRADS 3 or greater index lesion underwent FB at a single academic center previously naive to FB technology. Outcomes are detection rates for Gleason 6 cancer, csPCa, and any cancer. Multiple logistic regression with model selection was used to select covariates having significant effects on the outcome. Results Prostate cancers were identified in 52% of cases in patients with prior negative prostate biopsies. Among patients diagnosed with prostate cancer, 80% were clinically significant. The detection rates of csPCa using FB when a PIRADS 3, 4, or 5 index lesion was present on mpMRI were 6%, 46%, and 66%, respectively. PI-RADS v2 score had a predictive accuracy (AUC) of 0.79 for csPCa detection. Institutional experience over time, MRI-estimated prostate volume, and PI-RADS v2 score were independent predictors of csPCa using FB. Conclusions Since FB is a highly technique-driven process, development of internal quality measures to assess the institutional learning curve and the quality of PI-RADS v2 scoring is critical with adoption of this technology.

Multiparametric magnetic resonance (MR) imaging of the prostate combines both morphological and functional MR techniques by utilizing small field of view T1-weighted, T2-weighted, diffusion-weighted imaging, dynamic contrast-enhanced imaging, and MR spectroscopy to accurately detect, localize, and stage primary and recurrent prostate cancer. Localizing the site of recurrence in patients with rising prostate-specific antigen following treatment affects decision making regarding treatment and can be accomplished with multiparametric prostate MR. Several different treatment options are available for prostate cancer including radical prostatectomy, external beam radiation therapy, brachytherapy, androgen deprivation therapy, or a number of focal therapy techniques. The findings of recurrent prostate cancer can be different depending on the treatment the patient has received, and the radiologist must be able to recognize the variety of imaging findings seen with this common disease. This review article will detail the findings of recurrent prostate cancer on multiparametric MR and describe common posttreatment changes which may create challenges to accurate interpretation.

The authors describe their experience with magnetic resonance imaging (MRI) in the evaluation of pathologic conditions of the wrist in an outpatient setting. In that setting, because time and quality are both important factors, they have concentrated on developing protocols that will allow effective, time-efficient, high-resolution MRI of the wrist. With these wrist imaging protocols, they have evaluated the majority of commonly encountered pathologic conditions of the wrist. They have found that high-resolution images, which can be acquired in a very timely fashion when fast spin echo sequences are used in imaging protocols, will demonstrate the most common pathologic conditions, including triangular fibrocartilage and ligament tears in the wrist. They present the practical issues of patient position and imaging sequences as well as the imaging findings in those pathologic conditions.

Twenty-three cadaver forearm specimens were mounted on a Plexiglas acrylic plastic base for study of the trapeziometacarpal joint. Extrinsic and intrinsic motors were loaded to simulate lateral pinch, and pressure-sensitive film was used to record joint contact patterns in various functional positions. The palmar compartment of the trapeziometacarpal joint was the primary contact area during flexion adduction of the thumb ray in lateral pinch. Simulation of dynamic pinch and release produced dorsal enlargement of the contact pattern, suggesting physiologic translation of the metacarpal on the trapezium. Detachment of the palmar beak ligament resulted in dorsal translation of the contact area, producing a pattern similar to that of cartilage degeneration seen in the osteoarthritic joint. End-stage osteoarthritic specimens had a nonfunctional beak ligament and demonstrated a pathologic total contact pattern of joint congruity that was unaffected by further manipulations of the beak ligament. This work defines the contact patterns in the normal and diseased trapeziometacarpal joint and establishes the important influence of the palmar beak ligament on those contact areas.

Much controversy exists surrounding the utility of plain film, computed tomography, magnetic resonance imaging (MRI), and bone scintigraphy in the evaluation of sports-related spine injuries. The articles reviewed here offer several different perspectives. Cervical spine radiography, return-to-play criteria following cervical trauma, lumbar pain and pars injuries, utility of MRI in acute sports injuries, and sports-specific injuries are reviewed. The relationship between bone mineral density and sports activity is also reviewed.

Study design In a retrospective study, multiple examiners reviewed lumbar magnetic resonance imaging scans to develop a new grading system for lumbar pars interarticularis stress reaction and spondylolysis. The resulting system can be used as a mechanism for classifying patients, and as a measurement tool for future studies assessing the outcome efficacy of lumbar magnetic resonance imaging in patients with abnormalities of the pars interarticularis. Objective To determine the reliability of patient assignment to five different grades of bone stress reaction involving the lumbar pars interarticularis. Summary of background data Injury to the lumbar pars interarticularis (spondylolysis) is reported to be a common cause of low back pain in young patients. High-field-strength magnetic resonance imaging using fat saturation techniques and dedicated coil technology is sensitive in detecting bone stress injuries of the lumbar pars interarticularis, and thus is an excellent method for diagnosis. It also may be useful in prognostic decision making for these patients. A reliable classification system is a fundamental requirement for performing the research assessing the relationship between lumbar MRI findings and prognosis. Methods For this study, 55 young athletic patients undergoing evaluation for low back pain with suspected stress injury to the lumbar pars interarticularis underwent standardized lumbar magnetic resonance imaging using a 1.5-T scanner. Magnetic resonance images were reviewed by three readers using a new magnetic resonance classification system developed for lumbar spondylolysis. The findings were assessed for both interobserver and intraobserver reliability for five possible combinations in a 5-grade classification system. Results On magnetic resonance imaging, 42% of the patients demonstrated signal abnormalities of the lumbar pars interarticularis. The intraobserver and interobserver reliability coefficients for assigning the grade of pars interarticularis abnormality ranged, respectively, from 0.766 (95% confidence interval [CI], 0.62-0.91) to 0.906 (95% CI, 0.80-1), and from 0.706 (95% CI, 0.55-0.86) to 1. Conclusions Magnetic resonance findings of stress reactions and spondylolysis of the lumbar pars interarticularis can be reliably classified into five grades by experienced readers. Further study is needed to determine the role of these findings in the management of young athletic patients with low back pain.

This report describes the gray-scale and color Doppler sonographic appearance of healed Achilles tendon ruptures that have been treated nonoperatively.Eleven patients with acute Achilles tendon ruptures were studied with sonography in the acute setting and following nonoperative management of their torn tendon.On sonographic examination, healed tendons treated nonoperatively are characterized by mild residual distortion of the normal fibrillar architecture of the tendon, anterior bulging or irregularity of the healed tendon, and a hypoechoic area about the site of rupture. Less frequent observations include mildly increased color flow and calcification at the rupture site. The previously described findings of acute tears, including hematomas, gaps at the rupture site, hyperemic torn tendon ends, and markedly distorted fibrillar architecture, were seen to have resolved in this series.The Achilles tendon tear treated nonoperatively has a different sonographic appearance from that of a normal or acutely ruptured tendon.

Study design A cross-sectional study comparing the relationship of symptoms with anatomic impairment visible on lumbar magnetic resonance imaging in 408 symptomatic subjects. Objective To determine how various anatomic impairments, including the magnitude and location of nerve compression visible on lumbar magnetic resonance imaging, are associated with patient reports of pain, weakness, and dysesthesia. Summary and background data Anatomic impairments of the intervertebral disc, radicular canal, and associated soft tissues are prevalent in people with and those without low back pain or lower extremity radiculopathy. This has led to confusion in differentiating between symptom generators and benign variation visible on lumbar magnetic resonance imaging. Recent literature has suggested that the presence of nerve compression is an important finding in the prediction of symptoms. However, the threshold for meaningful nerve compression has not been described. Methods In this study, 408 participants undergoing a diagnostic workup for low back pain, radiculopathy, and/ or completed a survey and pain drawing. Participants underwent standardized lumbar magnetic resonance imaging using a 1.5-T scanner. Two classification systems describing the spatial distribution of symptoms were developed. An additional system to quantify the magnitude of nerve and thecal sac compression was created. All systems were assessed for reliability, after which comparisons among variables were performed using Chi2 as well as simple and multiple logistic regression analysis. Results The reliability coefficients for categorizing patients on the basis of pain drawing ranged from 0. 75 to 0.88. The S1-S2 segmental distribution was the most commonly reported location of symptoms, followed by L4-L5. The most common magnetic resonance imaging diagnosis was "unremarkable," followed by "disc impairment without nerve compression." Disc extrusion was present in 10.8% of participants. The reliability of classifying nerve compression visible on magnetic resonance imaging ranged from 0.27 to 1. Nerve compression was present in 37% of participants, and 18% had severe nerve compression. There were no significant associations between segmental distribution of symptoms and the presence of anatomic impairment. However, according to a collapsed classification scale, severe nerve compression and disc extrusion were predictive of pain distal to the knee (odds ratios, 2.72 and 3. 34). The self-report of weakness was associated mildly with severe nerve compression and disc extrusion, but not with other findings. Magnetic resonance imaging findings did not predict self-reports of dysesthesia. Conclusions The presence of disc extrusion and/or ipsilateral, severe nerve compression at one or multiple sites is strongly associated with distal leg pain. Mild to moderate nerve compression, disc degeneration or bulging, and central spinal stenosis are not significantly associated with specific pain patterns. Although segmental distributions of pain can be determined reliably from pain drawings, this finding alone is of little use in predicting lumbar impairment. The self-report of lower extremity weakness or dysesthesia is not significantly related to any specific lumbar impairments. [Key words: back pain, diagnosis, magnetic resonance imaging, nerve compression, pain drawing, pathology]

Rationale and Objectives. The authors evaluated radiologic consultation affecting resident physician ordering of relatively expensive imaging studies. Methods. Requisitions ( n = 180) for expensive imaging studies from three general medicine floors (two consultation floors, one control floor) were prospectively evaluated. Information on the requisitions was classified as appropriate, inappropriate, or undecided if insufficient information was provided. On the consultation floors, but not the control floor, the medical residents were contacted about all studies initially considered inappropriate or undecided before they were performed. Results. Nine of 119 requisitions (7.6%) from the consultation floors were considered inappropriate. In three studies (2.5%) the imaging evaluation was modified as the result of the interaction with the radiologist. There was no significant difference in the total number of radiologic studies or percentage of the total that were expensive imaging studies when comparing the consultation floors with the control floor. Conclusion. Radiologic consultation on expensive imaging studies through routine review of requisitions did not significantly change their use by house staff.