MRI Lesions Research Articles

Abstract PO2-22-06: MRI response Assessment of Single Fraction Pre-operative Stereotactic Radiotherapy: Preliminary results

Abstract Background: Pre-operative stereotactic breast irradiation (SPBI) improves targeting precision and has the potential to decrease treatment-related toxicity while downstaging or eliminating cancer. Accurate pCR prediction may allow omission of surgery. We are reporting initial interim results of the performance of multiparametric breast MRI in identifying pathologic response rate after single-fraction pre-operative SPBI in early stage estrogen receptor-positive (ER+), HER-2 negative breast cancer. Methods: In an ongoing single center prospective single-arm trial 22 patients with ER+/HER2-negative, cN0, unifocal, invasive breast cancer ≤3 cm underwent single-dose ablative SPBI, followed by definitive surgery per standard of care. Residual disease vs complete imaging response to SPBI was assessed on baseline and post-SPBI/pre-operative breast MRI. Pathologic response was categorized using MDACC Residual Cancer Burden (RCB) Categories. Wilcoxon rank sum test was used to assess the correlation of pathologic complete response (pCR) or RCB status on final path with MRI lesion size, volume, diffusion weighted imaging apparent diffusion coefficient (ADC) value, and when available, presence of residual enhancement on pre-operative MRI. MRI volume and ADC values were obtained using a dedicated CAD software. Area under the receiver operating Curve(AUC) was constructed to assess the diagnostic performance of pre-operative MRI on predicting pathologic response. Results Mean patient age was 64.9 (SD±7.3) years, tumor diameter 1.2(± 0.6) cm, pre-SPBI volume 6.4 ± 9.1 cm3, post SPBI volume 1.8 ± 5.6 cm3, ADC 0.91 ×10-3 mm2/s. At surgical pathology, 6(27.2%) achieved pCR/RCB-0, 9(41%) RCB-I, 7(31.8%) RCB-II. Mean baseline MRI size (1.2 ± 0.7 vs 1.3 ± 0.6, p=0.88), enhancement volumes (6.0±6.2 vs 7.9±9.9 cm3, p=0.59), DWI ADC values (1.1 ± 0.3 vs 0.9 ± 0.2 mm2/s, p-0.48) were not significantly different between tumors that showed pCR vs RCB I-II at surgical pathology. Time elapsed from SBRT to surgery were significantly longer in patients with pCR (264.3 ± 74.2 vs 183.7 ± 68.3 days, p=0.04) On pre-op MRI, mean enhancement volume was smaller in cancers that had pCR, however it did not reach significance (0.1 ± 0.1 vs 2.1 ± 6.0 cm3, p=0.2). Of 18 patients with available pre-operative MRI, residual enhancement was present in 7, of these 6/7(87%) had RCB I-II, and 1/7(13%) RCB-0 at surgical pathology. Conversely, in 11 patients with no residual enhancement on MRI, pathology showed pCR/RCB-0 in 5(45.5%), while 6(54.5%) had RCB I or II. Presence of residual enhancement on pre-operative MRI had an AUC of 0.68 (95%CI 0.43; 0.93, p=0.2) in predicting residual cancer after SPBI. Conclusion: Detecting residual enhancement on pre-operative MRI is a strong indicator of residual disease after SPBI, while lack of enhancement is not a reliable predictor of pCR. Our preliminary results do not indicate an association between baseline MRI enhancement volume, DWI ADC and pathologic response. Citation Format: Baṣak Dogan, Sunati Sahoo, Marilyn Leitch, Prasanna Alluri, Robert Timmerman, Deborah Farr, Asal Rahimi. MRI response Assessment of Single Fraction Pre-operative Stereotactic Radiotherapy: Preliminary results [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-22-06.

Evaluating the utility of serum NfL, GFAP, UCHL1 and tTAU as estimates of CSF levels and diagnostic instrument in neuroinflammation and multiple sclerosis

BackgroundThis study aimed to evaluate the utility of neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase L1 (UCHL1) and total tau (tTAU) serum concentrations as approximation for cerebrospinal fluid (CSF) concentrations of the respective biomarkers in the context of neuroinflammation and multiple sclerosis (MS). MethodsNfL, GFAP, UCHL1 and tTAU concentrations in serum and CSF were measured in 183 patients (122 with neuroinflammatory disease and 61 neurological or somatoform disease controls) using the single molecule array HD-1 analyzer (Quanterix, Boston, MA). Spearman's rank correlations were computed between serum and CSF concentrations. In a second step, the effects of age, BMI, gadolinium-enhancing lesions in MRI, integrity of the blood–brain barrier (BBB) and presence of acute relapse were accounted for by computing partial correlations. The analyses were repeated for a subsample consisting of MS phenotype patients only (n = 118). EDSS, MS disease activity and acute relapse were considered as additional covariates. Receiver operating characteristic (ROC) analysis was performed for each serum/CSF biomarker concentration to assess how well the particular biomarker concentration differentiates MS patients from somatoform disease controls. Correlations between serum and CSF levels as well as area under the curve (AUC) values were compared for the different biomarkers using z-test statistics. ResultsSerum concentrations correlated positively with CSF levels for NfL (r = 0.705, p < 0.01) as well as for GFAP (r = 0.259, p < 0.01). Correlation coefficients were significantly higher for NfL than for GFAP (z = 5.492, p < 0.01). We found no significant serum-CSF correlations for UCHL1 or tTAU. After adjusting for covariates, the results remained unchanged. In the analysis focusing only on MS patients, the results were replicated. ROC analysis demonstrated similarly acceptable performance of serum and CSF NfL values in differentiating MS phenotype patients from somatoform disease controls. AUC values were significantly higher for serum and CSF NfL compared to other biomarkers. ConclusionNfL and GFAP but not UCHL1 or tTAU serum concentrations are associated with CSF levels of the respective biomarker. NfL exhibits more robust correlations between its serum and CSF concentrations as compared to GFAP independently from BBB integrity, clinical and radiological covariates. Both serum and CSF NfL values differentiate between MS and controls.

Clinical correlation between disease progression and central vein sign in pediatric onset multiple sclerosis: A binational study

BackgroundThe central vein sign (CVS) has been proposed as a novel MRI biomarker to improve diagnosis of pediatric-onset MS (POMS). However, the role of CVS in POMS progression has yet to be discovered. ObjectivesTo investigate the appearance of CVS and its correlation with POMS disease progression. MethodsOne hundred fifty-six POMS from two MS centers in Israel and Czech Republic MS centers were followed for five years. Patient assessment was performed by the Expanded Disability Status Scale (EDSS) and Annual Relapse Rate (ARR). Patients in whom at least 40 % of brain MRI lesions had CVS (“rule of 40”) were determined as CVS-positive. ResultsThe total group of POMS consisted of 96 CVS-negative (61.5 %), aged 14.6 ± 1.9 years, EDSS 2.0, 75 % Interquartile Range (IQR) 1.0–3.0, disease duration (DD) 6.28 ± 0.38 years, and 60 CVS-positive (38.5 %), aged 15.1 ± 0.3 years, EDSS 2.0, IQR 1.5–3.0, DD 5.62 ± 0.13 years, were analyzed. After a three and five-year follow-up, the CVS-positive patients had higher EDSS scores than those who were CVS-negative, 2.0, IQR 1.0–2.5, vs 1.0, IQR 1.0–2.0, (p = 0.009) and 2.0, IQR 1.0–3.25 vs 1.0, IQR 1.0–2.0, (p = 0.0003), respectively. Patients with CVS-positive POMS were characterized by a significantly higher ARR (0.78 ± 0.08 vs 0.57 ± 0.04, p = 0.002). These results were confirmed in subgroups of Disease Modifying Treatments (DMT) untreated and treated patients. ConclusionCVS-positive POMS is characterized by higher disability progression than CVS-negative, indicating the importance of CVS in disease pathogenesis.

Thin-slice elbow MRI with deep learning reconstruction: Superior diagnostic performance of elbow ligament pathologies

PurposeWith the slice thickness routinely used in elbow MRI, small or subtle lesions may be overlooked or misinterpreted as insignificant. To compare 1 mm slice thickness MRI (1 mm MRI) with deep learning reconstruction (DLR) to 3 mm slice thickness MRI (3 mm MRI) without/with DLR, and 1 mm MRI without DLR regarding image quality and diagnostic performance for elbow tendons and ligaments. MethodsThis retrospective study included 53 patients between February 2021 and January 2022, who underwent 3 T elbow MRI, including T2-weighted fat-saturated coronal 3 mm and 1 mm MRI without/with DLR. Two radiologists independently assessed four MRI scans for image quality and artefacts, and identified the pathologies of the five elbow tendons and ligaments. In 19 patients underwent elbow surgery after elbow MRI, diagnostic performance was evaluated using surgical records as a reference standard. ResultsFor both readers, 3 mm MRI with DLR had significant higher image quality scores than 3 mm MRI without DLR and 1 mm MRI with DLR (all P < 0.01). For common extensor tendon and elbow ligament pathologies, 1 mm MRI with DLR showed the highest number of pathologies for both readers. The 1 mm MRI with DLR had the highest kappa values for all tendons and ligaments. For reader 1, 1 mm MRI with DLR showed superior diagnostic performance than 3 mm MRI without/with DLR. For reader 2, 1 mm MRI with DLR showed the highest diagnostic performance; however, there was no significant difference. ConclusionsOne mm MRI with DLR showed the highest diagnostic performance for evaluating elbow tendon and ligament pathologies, with similar subjective image qualities and artefacts.

Treatment response as surrogate to predict risk for disease progression in pediatric medulloblastoma with persistent magnetic resonance imaging lesions after first-line treatment.

This study aims at clarifying the impact of persistent residual lesions following first-line treatment for pediatric medulloblastoma. Data on 84 pediatric patients with medulloblastoma and persistent residual lesions on centrally reviewed magnetic resonance imaging (MRI) at the end of first-line therapy were analyzed. Twenty patients (23.8%) had residual lesions in the tumor bed (R+/M0), 51 (60.7%) had distant lesions (R0/M+) and 13 (15.5%) had both (R+/M+). Overall response to first-line therapy was minor or partial (≥ 25% reduction, minor response [MR]/PR) for 64 (76.2%) and stable disease (SD) for 20 patients (23.8%). Five-year post-primary-treatment progression-free (pptPFS) and overall survival (pptOS) were superior after MR/PR (pptPFS: 62.5 ± 7.0%[MR/PR] vs. 35.9 ± 12.8%[SD], P = .03; pptOS: 79.7 ± 5.9[MR/PR] vs. 55.5 ± 13.9[SD], P = .04). Furthermore, R+/M + was associated with a higher risk for progression (5-year pptPFS: 22.9 ± 17.9%[R+, M+] vs. 72.4 ± 12.0%[R+, M0]; P = .03). Watch-and-wait was pursued in 58 patients, while n = 26 received additional treatments (chemotherapy only, n = 19; surgery only, n = 2; combined, n = 3; valproic acid, n = 2), and their outcomes were not superior to watch-and-wait (5-year pptPFS: 58.5 ± 7.7% vs. 51.6 ± 10.7% P = .71; 5-year pptOS: 76.3 ± 6.9% vs. 69.8 ± 9.7%, P = .74). For the whole cohort, 5-year pptPFS by molecular subgroup (58 cases) were WNT: 100%, SHH: 50.0 ± 35.4%, group-4, 52.5 ± 10.5, group-3 54.2 ± 13.8%; (P = .08). Overall response and extent of lesions can function as surrogate parameters to predict outcomes in pediatric MB patients with persistent lesions after first-line therapy. Especially in the case of solitary persistent medulloblastoma MRI lesions, additional therapy was not beneficial. Therefore, treatment response, extent/kind of residual lesions and further diagnostic information need consideration for indication of additional treatments for persisting lesions.

Prevalence of primary headaches in multiple sclerosis patients

BackgroundMultiple sclerosis (MS) is the most common immune-mediated inflammatory disease of the central nervous system. It is characterized by symptoms such as visual disturbances, paresis with spasticity, paresthesia, numbness, and fatigue. However, several studies have shown a high prevalence of headaches in individuals with MS. Migraine and tension-type headaches are the most frequent types of headaches experienced by those with MS. Additionally, the role of MS disease-modifying agents must be considered. These agents have different modes of action and side effect profiles, and their use may sometimes trigger headaches in patients with MS. ObjectivesThis study aimed to explore the prevalence and clinical characteristics of primary headaches in MS patients. The relationship between headache and clinical features of MS (Course of MS, duration, EDSS, brain imaging and DMD) are also investigated. Subjects and MethodsTwo hundred and eighty-one MS patients diagnosed according to according to the 2017 revisions to the McDonald Criteria were included in the study. Data was collected from the MS unit medical records and from the interview with the patients. Patients with reported headaches are asked to recall their headache characteristics and patterns using an interviewer administered Arabic language-structured validated questionnaire. ResultsThe median age of patients was 33 years old, with a range of 22–55. Tension-type headache (TTH) was more common in males, patients with more severe disability (EDSS ≥ 3), and those with SPMS and PPMS phenotypes. Additionally, patients on rituximab or cyclophosphamide therapy were more likely to have TTH. On the other hand, females, patients with milder disability (EDSS < 3), and those with RRMS phenotype were more likely to have migraine. This was also true for patients with MRI lesions involving the periaqueductal gray, and those receiving INF or fingolimod (P < 0.05). Periaqueductal gray matter lesions were found in the MRI of 48 patients (40 %) who experienced headaches on more than 10 days per month. Sensorimotor lesions in the brain were found in 55 patients (53.4 %) with severe headaches (p-value < 0.001). Interferons were associated with an increased risk of worsening preexisting headaches and the appearance of de novo headaches related to its intake (odds ratio: 2.84, 3.72; relative risk: 1.63, 2.04; p-value = 0.03, < 0.001, respectively). On the other hand, rituximab was associated with a decreased risk of worsening preexisting headaches and the appearance of de novo headaches related to its intake (odds ratio: 0.04, 0.09; relative risk: 0.11, 0.18; p-value = < 0.001, < 0.001, respectively). ConclusionPrimary headaches are a common occurrence in patients with MS. Migraines and tension-type headaches (TTH) are among the most prevalent types. It has been observed that interferon can exacerbate preexisting headaches and even cause new ones. Additionally, the location of MS plaques may play a role in the frequency and severity of headaches.

1135 Classification of Temporal Lobe Epilepsy Anatomo-clinico-electrical Hypotheses: A Stereo EEG Study

INTRODUCTION: Temporal lobe epilepsy (TLE) has historically been divided into mesial and lateral (neocortical) TLE, but electrophysiological, semiological, and anatomical evidence indicate that the epileptogenic zone (EZ) and areas of propagation involve both temporal and extratemporal structures. Hypothesis-driven, structured interrogation is crucial for a successful stereo EEG (SEEG) exploration and subsequent successful surgical intervention. METHODS: 59 patients (ages 19-77) with drug-resistant TLE underwent SEEG at our institution from 2020-2022. We retrospectively reviewed each patient’s multidisciplinary discussions, history, imaging, and outcomes. We proposed four types of implantation hypotheses: temporal, temporal/basal/occipital, anterior perisylvian, and perisylvian. We quantitatively validated these types against anatomic coverage and semiology using unsupervised clustering and clinically by comparing classification to rates of successful localization of the epileptogenic zone (EZ) and seizure outcomes. RESULTS: Temporal (only) hypotheses were the least frequent (13.6%), followed by temporal/basal/occipital (25.4%), anterior perisylvian (30.5%), and perisylvian (30.5%). The hypotheses were not different in age at SEEG (p = 0.32), sex (p = 0.67), and handedness (p = 0.33). Frequent semiological features by type were: temporal – autonomic features, dÉjÀ vu; temporal/basal/occipital – visual and language disturbance; anterior perisylvian – oromotor; perisylvian – sensory manifestation. Clustering was validated against semiology (RI = 0.63) and lobar coverage (RI = 0.73). Successful localization of the EZ occurred in 79.7% and did not associate with hypothesis type (p = 0.22). Hypothesis type (p = 0.30) or EZ localization (p = 1.00) did not associate with the presence of an MRI lesion. 6-month Engel 1a rate was 71% and did not vary by hypothesis type (p = 0.29). CONCLUSIONS: The anatomo-clinico-electrical hypotheses in TLE must consider both temporal and extratemporal structures and not be limited by a medial vs. lateral TLE mindset. This proposed classification of TLE hypotheses can serve as starting point for multidisciplinary patient discussion as well as a tool to compare SEEG exploration and outcomes across centers.

Brain magnetic resonance imaging and computed tomography findings in cats and dogs with central nervous system cryptococcosis in Australia: 23 cases (2009-2020).

To describe the imaging findings in Australian cats and dogs with CNS cryptococcosis. 23 cases (10 cats; 13 dogs) with CNS cryptococcosis and brain MRI or CT studies available to review. Retrospective, multi-institutional case series. Brain MRI or CT studies were reviewed by a board-certified radiologist. Imaging findings were described and the differences between cats and dogs explored. Morphologic features were consistent with extra-axial lesions in all (n = 13) dogs and either intra-axial (5/10) or extra-axial (4/10) lesions in cats, with 1 cat having no detectable lesions in low-field brain MRI scans. Meningeal abnormalities were most common, followed by forebrain and cerebellar lesions. Intracranial MRI lesions were typically T2 hyperintense and T1 hypo- to isointense. Four cases had T2 hypointense lesions affecting the brain, sinonasal cavity, or regional lymph nodes. Intracranial CT lesions were mostly soft tissue attenuating. Contrast enhancement was present in all cases with contrast series available, with ring enhancement shown only in cats. Osteolysis was more common in dogs than cats, particularly affecting the cribriform plate. All 13 dogs and many (6/10) cats had at least 1 lesion affecting sinonasal or contiguous tissues, and locoregional lymphadenomegaly was common (7/10 cats; 11/13 dogs). Imaging lesions in cryptococcal meningoencephalitis were extra-axial in dogs but could be intra-axial or extra-axial in cats. Careful examination for extracranial lesions (sinonasal, retrobulbar, facial soft tissue, tympanic bullae, or locoregional lymph nodes) is important to provide alternative safe biopsy sites. T2 hypointense lesions, while rare, should prompt consideration of cryptococcosis.

Bio-Medical Image Segmentation And Detection For Brain Tumour And Skin Lesions Diseases Through U-NET

Abstract: The research concentrates on enhancing the precise identification and localization of diseases within medical images, a pivotal component of medical imaging analysis crucial for diagnoses and treatment planning. Employing the U-Net architecture, renowned for its effectiveness in biomedical image segmentation, the study targets the detection of brain tumors and skin lesions in MRI or CT scans. Remarkably, the proposed method not only identifies diseases but also provides intricate details regarding their dimensions and spatial arrangement. Extensive experimental validation showcases the method's superiority over existing approaches, underscoring its potential for holistic learning in medical image analysis.

Retrospective Evaluation of Attacks, EDSS Scores, and MRI Changes Before the Start of Treatment and One Year After the Start of Treatment in Patients Followed by a Diagnosis of Multiple Sclerosis and Using Ocrelizumab in Our Clinic

Objective: Depletion of B cells by anti-CD20 monoclonal antibodies has been proven to reduce relapsing remitting multiple sclerosis (RRMS) activity and progression of primary progressive MS (PPMS). In our study, we aimed to retrospectively present our clinical experience and contribute to real-life data after the use of Ocrelizumab. Material and Methods: Patients aged 18-55 years using Ocrelizumab and diagnosed with MS by McDonald's 2017 criteria were included. Neurological examination findings and EDSS findings available in our file records were used to evaluate the level of disability. Patients with MRI lesions consistent with their clinical complaint lasting more than 24 hours were evaluated as an attack. Patients' ages, MS diagnosis times, and previous immune modulatory treatments were recorded. The number of T2, FLAIR sequence MRI lesions, EDSS before ocrelizumab, and the number of T2, FLAIR sequence MRI lesions 1 year after receiving ocrelizumab were recorded. After 1 year of follow-up, the absence of attacks, no increase in the number of lesions in MRI, and no progress in EDSS were accepted as NEDA 3. Results: Our cases in this study include 30 MS patients. Patients were 26.7% relapsing remitting MS (RRMS), 26.7% primary progressive MS (PPMS), and 46.7% secondary progressive MS (SPMS). There was no attack in 87.5% of the RRMS patient group. In the SPMS patient group, no attacks were observed after ocrelizumab in the cases with attacks. In our study, the rate of patients who did not develop new T2 lesions and whose lesions disappeared was 62.5% in the RRMS patient group, 78.5% in the SPMS patient group, and 75% in the PPMS patient group. In the total patient group, the rate of patients without EDSS increase was 93% (28 patients). Conclusion: In our study, it was determined that ocrelizumab was effective by reducing the attack rates, preserving the EDSS scores and preventing the increase in the lesion burden. Our findings are consistent with real-life data.

Are systematic prostate biopsy still necessary in biopsy naive men?

Multiparametric MRI and the transperineal approach have become standard in the diagnostic pathway for suspected prostate cancer. Targeting of MRI lesions is performed at most centers, but the routine use of systematic cores is controversial. We aim to assess the value of obtaining systematic cores in patients undergoing cognitive fusion targeted double-freehand transperineal prostate biopsy. Patients who underwent a cognitive fusion, freehand TPB at a single tertiary urology service (Perth, Australia) between November 2020 and November 2021 were retrospectively reviewed. Patients were included if they were biopsy naive and had a clinical suspicion of prostate cancer, based on their mpMRI results. Both targeted and systematic cores were taken at the time of their biopsy. One hundred forty patients suited the selection criteria. Clinically significant cancer was identified in 63% of patients. Of those that had clinically significant cancer, the target lesion identified 91% of the disease, missing 9% of patients whom the target biopsy detected non-clinically significant cancer but was identified in the systematic cores. Higher PI-RADS category patients were also found to be associated with an increasing likelihood of identifying clinically significant cancer within the target. In patients with PI-RADS 3 and higher, the target biopsy can miss up to 9% of clinically significant cancer. Systematic cores can add value as they can also change management by identifying a high-risk disease where only intermediate cancer was identified in the target. A combination of targeted and systematic cores is still required to detect cancer.

Early prediction of unfavorable evolution after a first clinical episode suggestive of multiple sclerosis: the EUMUS score.

Predicting disease progression in patients with the first clinical episode suggestive of multiple sclerosis (MS) is crucial for personalized therapeutic approaches. This study aimed to develop the EUMUS score for accurately estimating the risk of early evidence of disease activity and progression (EDA). Retrospective analysis was conducted on data from 221 patients with a first clinical MS episode collected from four Italian MS centers. Various variables including socio-demographics, clinical features, cerebrospinal fluid analysis, evoked potentials, and brain MRI were considered. A prognostic multivariate regression model was identified to develop the EUMUS score. The optimal cutoff for predicting the transition from no evidence of disease activity (NEDA3) to EDA was determined. The accuracy of the prognostic model and score were tested in a separate UK MS cohort. After 12 months, 61.54% of patients experienced relapses and/or new MRI lesions. Younger age (OR 0.96, CI 0.93-0.99; p = 0.005), MRI infratentorial lesion(s) at baseline (OR 2.21, CI 1.27-3.87; p = 0.005), positive oligoclonal bands (OR 2.89, CI 1.47-5.69; p = 0.002), and abnormal lower limb somatosensory-evoked potentials (OR 2.77, CI 1.41-5.42; p = 0.003) were significantly associated with increased risk of EDA. The EUMUS score demonstrated good specificity (72%) and correctly classified 80% of patients with EDA in the independent UK cohort. The EUMUS score is a simple and useful tool for predicting MS evolution within 12 months of the first clinical episode. It has the potential to guide personalized therapeutic approaches and aid in clinical decision-making.

Substantial and comparable suppression of disease activity following early initiation of cladribine tablets, ocrelizumab or alemtuzumab as first pharmacologic treatment for relapsing multiple sclerosis: A real world study

BackgroundWe describe the efficacy and safety of recent high efficacy disease DMTs in DMT-naive patients with highly active RMS. MethodsThis was a retrospective, cross sectional study from the Kuwait national MS registry. Patients with RMS who received alemtuzumab, cladribine tablets or ocrelizumab as their first DMT for RMS, with ≥2 year of follow up were included. The primary endpoint was the change in relapse rate from treatment initiation to 1 year; changes in disability (Expanded Disability Status Scale [EDSS]), radiologic activity, the proportion with no evidence of disease activity-3 (NEDA-3), and the frequency of adverse events were secondary endpoints. ResultsAmong 123 RRMS patients, 59 received ocrelizumab, 32 received cladribine tablets and 32 received alemtuzumab. About two-thirds (65%) were women. Substantial and similar (p>0.05) reductions occurred at the end of follow-up in annual relapse rate (by 93.2% for ocrelizumab, 87.5% for cladribine tablets, and 90.6% for alemtuzumab). The proportion with new T2 of gadolinium-enhancing MRI lesions across the three groups was reduced from 85–100% to 7–13%. Rates of confirmed disability progression were low (ocrelizumab 6.9%, cladribine tablets 3.1%, alemtuzumab 0%; p=0.280); disability was reduced in 15%, 22% and 38%, respectively. NEDA-3 was observed in 89.8%, 87.5%, and 84.4, respectively (p=0.784). No new or unexpected safety issues occurred. ConclusionOcrelizumab, cladribine tablets and alemtuzumab reduced relapse rates and MRI activity, and prevented disease progression, when are initiated early in DMT-naive RMS patients. These data support the early use of high-efficacy DMTs for people with highly active RMS.

Evaluation of Features in Probably Benign and Malignant Nonmass Enhancement in Breast MRI.

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a highly sensitive breast imaging modality in detecting breast carcinoma. Nonmass enhancement (NME) is uniquely seen on MRI of the breast. The correlation between NME features and pathologic results has not been extensively explored. Our goal was to evaluate the characteristics of probably benign and suspicious NME lesions in MRI and determine which features are more associated with malignancy. We performed a retrospective research after approval by the hospital ethics committee on women who underwent breast MRI from March 2017 to March 2020 and identified 63 lesions of all 400 NME that were categorized as probably benign or suspicious according to the BI-RADS classification (version 2013). MRI features of NME findings including the location, size, distribution and enhancement pattern, kinetic curve, diffusion restriction, and also pathology result or 6-12-month follow-up MRI were evaluated and analyzed in each group (probably benign or suspicious NME). Vacuum-guided biopsies (VAB) were performed under mammographic or sonographic guidance and confirmed with MRI by visualization of the inserted clips. Segmental distribution and clustered ring internal enhancement were significantly associated with malignancy (p value<0.05), while linear distribution or homogeneous enhancement patterns were associated with benignity (p value <0.05). Additionally, the plateau and washout types in the dynamic curve were only seen in malignant lesions (p value <0.05). The presence of DWI restriction in NME lesions was also found to be a statistically important factor. Understanding the imaging findings of malignant NME is helpful to determine when biopsy is indicated. The correlation between NME features and pathologic results is critical in making appropriate management.

Sex impacts treatment decisions in multiple sclerosis.

Individual disease-modifying treatment (DMT) decisions might differ between female and male people with MS (pwMS). To identify sex-related differences in DMT strategies over the past decades in a real-world setting. In this cohort study, data from the Austrian Multiple Sclerosis Treatment Registry (AMSTR), a nationwide prospectively collected registry mandatory for reimbursement, were retrospectively analyzed. Of 4840 pwMS, those with relapsing-remitting MS, aged at least 18years, who started DMT and had at least two clinical visits, were identified. At baseline, demographics, Expanded Disability Status Scale (EDSS) score, annualized relapse rate (ARR) in the prior 12months and MRI lesion load were assessed. At follow-up, ARR, EDSS scores, and DMT were determined. A total of 4224 pwMS were included into the study and had a median of 10 (IQR 5-18) clinical visits over an observation period of 3.5 (IQR 1.5-6.1) years. Multivariable Cox regression analysis revealed that the probability of DMT escalation due to relapse activity was lower in female than male pwMS (HR 4.1 vs. 8.3 per ARR). Probability of discontinuing moderate-effective DMT was higher in female pwMS when they were younger (HR 1.03 per year), and lower in male pwMS at higher age (HR 0.92). Similarly, female pwMS were more likely to stop highly effective DMT than male pwMS (HR 1.7). Among others, the most frequent reason for DMT discontinuation was family planning in female pwMS. All sex-related effects were independent of disease activity, such as MRI lesion load, baseline ARR or EDSS. Real-world treatment decisions are influenced by sex-related aspects. Awareness of these associations should prevent unwarranted differences in MS care.

Impact of Immune Checkpoint Inhibitors on the Course of Multiple Sclerosis.

Immune checkpoint inhibitors (ICIs) are increasingly used in cancer treatment. Their mechanism of action raises the question of possible exacerbation of preexisting multiple sclerosis (MS). The aim of our study was to assess the risk of increased MS activity, defined by the occurrence of a relapse and/or a new MRI lesion, after ICI initiation. This French multicentric study collected retrospective and prospective data on patients with MS treated with ICIs after a cancer diagnosis. We identified 18 patients with a median age of 48 years. Three of them (17%), all aged 50 years or younger, with a relapsing-remitting course, showed clinical and/or radiologic signs of MS activity 3 to 6 months after ICI initiation. They had stopped disease-modifying treatment (DMT) several months earlier, at the time of cancer diagnosis. Only one had both clinical and MRI activity, with mild severity and complete recovery. Our study suggests that the overall risk of MS activity under ICI is low and could be mainly driven by DMT discontinuation, as in MS in general. Although larger studies are needed for better risk assessment in younger patients with more active disease, ICI should be considered when needed in patients with MS.

Practical Guide to VI-RADS: MRI Protocols, Lesion Characterization, and Pitfalls.

Urothelial carcinoma is the most common type of bladder cancer (BC), accounting for approximately 90% of all cases. Evaluating the depth of tumor invasion in the bladder wall (tumor staging) is essential for determining the treatment and prognosis in patients with BC. Neoadjuvant therapy followed by radical cystectomy is the most common treatment of localized muscle-invasive BC (MIBC). Therefore, it is vital to differentiate non-MIBC from MIBC. Transurethral resection of bladder tumor (TURBT) is the reference standard to determine the extent of tumor invasion into the bladder wall through tissue sampling. However, this diagnostic and therapeutic method may not adequately sample the muscularis propria, leading to a higher risk of residual disease, early recurrence, and tumor understaging in approximately 50% of patients during the initial TURBT. Multiparametric MRI can overcome some of the limitations of TURBT when evaluating BC, particularly regarding tumor staging. In this context, the Vesical Imaging Reporting and Data System (VI-RADS) classification was developed to establish standards for bladder multiparametric MRI and interpretation. It uses a 5-point scale to assess the likelihood of detrusor muscle invasion. T2-weighted MR images are particularly useful as an initial guide, especially for categories 1-3, while the presence of muscular invasion is determined with diffusion-weighted and dynamic contrast-enhanced sequences. Diffusion-weighted imaging takes precedence as the dominant method when optimal image quality is achieved. The presence of a stalk or a thickened inner layer and no evidence of interruption of the signal intensity of the muscular layer are central for predicting a low likelihood of muscle invasion. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Hoegger in this issue.

Encoder-Decoder Contrast for Unsupervised Anomaly Detection in Medical Images.

Unsupervised anomaly detection (UAD) aims to recognize anomalous images based on the training set that contains only normal images. In medical image analysis, UAD benefits from leveraging the easily obtained normal (healthy) images, avoiding the costly collecting and labeling of anomalous (unhealthy) images. Most advanced UAD methods rely on frozen encoder networks pre-trained using ImageNet for extracting feature representations. However, the features extracted from the frozen encoders that are borrowed from natural image domains coincide little with the features required in the target medical image domain. Moreover, optimizing encoders usually causes pattern collapse in UAD. In this paper, we propose a novel UAD method, namely Encoder-Decoder Contrast (EDC), which optimizes the entire network to reduce biases towards pre-trained image domain and orient the network in the target medical domain. We start from feature reconstruction approach that detects anomalies from reconstruction errors. Essentially, a contrastive learning paradigm is introduced to tackle the problem of pattern collapsing while optimizing the encoder and the reconstruction decoder simultaneously. In addition, to prevent instability and further improve performances, we propose to bring globality into the contrastive objective function. Extensive experiments are conducted across four medical image modalities including optical coherence tomography, color fundus image, brain MRI, and skin lesion image, where our method outperforms all current state-of-the-art UAD methods. Code is available at: https://github.com/guojiajeremy/EDC.

Whole-lesion assessment of volume and signal changes after sclerotherapy of extremity venous malformations

PurposeTo investigate quantitative changes in MRI signal intensity (SI) and lesion volume that indicate treatment response and correlate these changes with clinical outcomes after percutaneous sclerotherapy (PS) of extremity venous malformations (VMs). MethodsVMs were segmented manually on pre- and post-treatment T2-weighted MRI using 3D Slicer to assess changes in lesion volume and SI. Clinical outcomes were scored on a 7-point Likert scale according to patient perception of symptom improvement; treatment response (success or failure) was determined accordingly. ResultsEighty-one patients with VMs underwent 125 PS sessions. Treatment success occurred in 77 patients (95 %). Mean (±SD) changes were –7.9 ± 24 cm3 in lesion volume and –123 ± 162 in SI (both, P <.001). Mean reduction in lesion volume was greater in the success group (–9.4 ± 24 cm3) than in the failure group (21 ± 20 cm3) (P =.006). Overall, lesion volume correlated with treatment response (ρ = –0.3, P =.004). On subgroup analysis, volume change correlated with clinical outcomes in children (ρ = –0.3, P =.03), in sodium tetradecyl sulfate–treated lesions (ρ = –0.5, P =.02), and in foot lesions (ρ = –0.6, P =.04). SI change correlated with clinical outcomes in VMs treated in 1 PS session (ρ = –0.3, P =.01) and in bleomycin-treated lesions (ρ = –0.4, P =.04). ConclusionsChange in lesion volume is a reliable indicator of treatment response. Lesion volume and SI correlate with clinical outcomes in specific subgroups.

Drugs Targeting CD20 in Multiple Sclerosis: Pharmacology, Efficacy, Safety, and Tolerability.

Currently, there are four monoclonal antibodies (mAbs) that target the cluster of differentiation (CD) 20 receptor available to treat multiple sclerosis (MS): rituximab, ocrelizumab, ofatumumab, and ublituximab. B-cell depletion therapy has changed the therapeutic landscape of MS through robust efficacy on clinical manifestations and MRI lesion activity, and the currently available anti-CD20 mAb therapies for use in MS are a cornerstone of highly effective disease-modifying treatment. Ocrelizumab is currently the only therapy with regulatory approval for primary progressive MS. There are currently few data regarding the relative efficacy of these therapies, though several clinical trials are ongoing. Safety concerns applicable to this class of therapeutics relate primarily to immunogenicity and mechanism of action, and include infusion-related or injection-related reactions, development of hypogammaglobulinemia (leading to increased infection and malignancy risk), and decreased vaccine response. Exploration of alternative dose/dosing schedules might be an effective strategy for mitigating these risks. Future development of biosimilar medications might make these therapies more readily available. Although anti-CD20 mAb therapies have led to significant improvements in disease outcomes, CNS-penetrant therapies are still needed to more effectively address the compartmentalized inflammation thought to play an important role in disability progression.