Preoperative Pelvic Magnetic Resonance Imaging Research Articles

A comparative study of mono-exponential and advanced diffusion-weighted imaging in differentiating stage IA endometrial carcinoma from benign endometrial lesions

PurposeThe purpose of the current investigation is to compare the efficacy of different diffusion models and diffusion kurtosis imaging (DKI) in differentiating stage IA endometrial carcinoma (IAEC) from benign endometrial lesions (BELs).MethodsPatients with IAEC, endometrial hyperplasia (EH), or a thickened endometrium confirmed between May 2016 and August 2022 were retrospectively enrolled. All of the patients underwent a preoperative pelvic magnetic resonance imaging (MRI) examination. The apparent diffusion coefficient (ADC) from the mono-exponential model, pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction (f) from the bi-exponential model, distributed diffusion coefficient (DDC), water molecular diffusion heterogeneity index from the stretched-exponential model, diffusion coefficient (Dk) and diffusion kurtosis (K) from the DKI model were calculated. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic efficiency.ResultsA total of 90 patients with IAEC and 91 patients with BELs were enrolled. The values of ADC, D, DDC and Dk were significantly lower and D* and K were significantly higher in cases of IAEC (p < 0.05). Multivariate analysis showed that K was the only predictor. The area under the ROC curve of K was 0.864, significantly higher compared with the ADC (0.601), D (0.811), D* (0.638), DDC (0.743) and Dk (0.675). The sensitivity, specificity and accuracy of K were 78.89%, 85.71% and 80.66%, respectively.ConclusionAdvanced diffusion-weighted imaging models have good performance for differentiating IAEC from EH and endometrial thickening. Among all of the diffusion parameters, K showed the best performance and was the only independent predictor. Diffusion kurtosis imaging was defined as the most valuable model in the current context.

Surgical Staging of Differentiated Endometrial Cancer: An Analysis of Postoperative Outcome in a Gynecological Cancer Center in Sri Lanka.

Even though surgico-pathological staging is recommended in poorly differentiated endometrial cancer, management of differentiated endometrial cancer is controversial. Preoperative pelvic and abdominal Magnetic Resonance Imaging (MRI) is recommended in well-differentiatedendometrial cancer to identify patients with risk factors for regional metastasis. However, access to MRI is limited in Sri Lanka, and surgico-pathological staging is the primary staging method available for most patients with differentiated endometrial cancer. Our objective was to evaluate the outcome of surgical staging among differentiated endometrial cancer patients who underwent primary surgery at the gynecological cancer center of Apeksha Hospital Maharagama, Sri Lanka. A retrospective study was conducted using the ongoing electronic database at the gynecological cancer center of the National Cancer Institute (Apeksha Hospital) in Maharagama, Sri Lanka. Data from December 2019 to December 2020 were selected for analysis. During the study period, 112 patients with endometrial cancer underwent hysterectomy. This study included 90 patients with differentiated endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] Grade 1 and Grade 2), out of which pelvic lymph node dissection was performed in 78 (86.7%) cases. Among the 90 patients, 54 (60%) had medical comorbidities. It was reported that 35% (n=32) of the patients had myometrial invasion of more than 50% thickness. Furthermore, 13.8% of patients with deep myometrial invasion had lymph node metastasis, while only one patient (2%) in the superficial or no myometrial invasion group had lymph node metastasis. Therefore, the absence of deep myometrial invasion has a negative predictive value of around 98% for excluding pelvic lymph node metastasis. Approximately one in seven patients with deeply infiltrating differentiated endometrial cancer had lymph node metastasis. In limited resource settings where preoperative pelvic MRI is not readily available, implementing a policy of routine surgical pelvic lymph node assessment would be beneficial. This approach would aid in detecting stage IIIc disease and also help avoid unnecessary pelvic irradiation.

Uterine mesenchymal tumors: development and preliminary results of a magnetic resonance imaging (MRI) diagnostic algorithm.

The aim of our study is to propose a diagnostic algorithm to guide MRI findings interpretation and malignancy risk stratification of uterine mesenchymal masses with a multiparametric step-by-step approach. A non-interventional retrospective multicenter study was performed: Preoperative MRI of 54 uterine masses was retrospectively evaluated. Firstly, the performance of MRI with monoparametric and multiparametric approach was assessed. Reference standard for final diagnosis was surgical pathologic result (n = 53 patients) or at least 1-year MR imaging follow-up (n = 1 patient). Subsequently, a diagnostic algorithm was developed for MR interpretation, resulting in a Likert score from 1 to 5 predicting risk of malignancy of the uterine lesion. The accuracy and reproducibility of the MRI scoring system were then tested: 26 preoperative pelvic MRI were double-blind evaluated by a senior (SR) and junior radiologist (JR). Diagnostic performances and the agreement between the two readers with and without the application of the proposed algorithm were compared, using histological results as standard reference. Multiparametric approach showed the best diagnostic performance in terms of accuracy (94.44%,) and specificity (97.56%). DWI was confirmed as the most sensible parameter with a relative high specificity: low ADC values (mean 0.66) significantly correlated to uterine sarcomas diagnosis (p < 0.01). Proposed algorithm allowed to improve both JR and SR performance (algorithm-aided accuracy 88.46% and 96%, respectively) and determined a significant increase in inter-observer agreement, helping even the less-experienced radiologist in this difficult differential diagnosis. Uterine leiomyomas and sarcomas often show an overlap of clinical and imaging features. The application of a diagnostic algorithm can help radiologists to standardize their approach to a complex myometrial mass and to easily identify suspicious MRI features favoring malignancy.

High intensity focused ultrasound treatment for adenomyosis: comparison of efficacy based on MRI features

Objective To compare the clinical efficacy of High intensity-focused ultrasound(HIFU) for different types of adenomyosis classified by magnetic resonance imaging (MRI). Methods A total of 227 patients with adenomyosis who underwent HIFU treatment in Suining Central Hospital from January 2014 to December 2019 were included. Based on the preoperative pelvic MRI examination and Kishi isometric classification method, the patients were divided into 4 types according to the location of lesions. There were 82 cases of type I (endogenous type), 75 cases of type II (exogenous type), 34 cases of type III (nodular type), and 36 cases of type IV (heterogeneous type). The results of HIFU treatment for four types of adenomyosis and intraoperative adverse effects were analyzed. The changes of lesion size, dysmenorrhea, and menstrual volume were analyzed at 3 and 6 months after the operation. Result (1) adverse effects: All patients successfully accepted HIFU treatment under sedation and analgesia. Grade A adverse effects occurred in 51 cases (22.47%) and grade B adverse effects in 3 cases (1.32%). The incidence of adverse effects in type I–IV patients was 21.95%, 22.66%, 23.53%, and 30.56%, respectively. There was no significant difference in the incidence of grade A and B adverse effects in all types, and no grade C–F adverse effects occurred. (2) Ablation effect: The ablation rate of type III(nodular type)patients was (74.7 ± 20.3) %, which was significantly higher than that of the other three types (p < .05). (3) Changes in lesion size: the lesion size of all patients decreased after treatment and the reduction rate gradually increased with time. At 6 months after the operation, the lesion reduction rate of type III patients was (70.8 ± 14.8) %, higher than that of the other three types patients (p < .05). There was no significant difference in the reduction rate of type I, type II and type IV. (4) Remission of menorrhagia: At 6 months after the operation, the total remission rate of type III patients was 100%, while the total remission rate of type IV patients (65.4%, 17/26) that was lower than that of type I, II and III patients(p < .05). (5) Dysmenorrhea relief: At 6 months after the operation, the total dysmenorrhea relief rate of type III patients was 100% and the complete relief rate (28.1%, 18/31) was higher than that of the other three types, which was significant differences (p < .05). Conclusions HIFU is safe and effective in the treatment of different types of adenomyosis, the therapeutic effect of HIFU in patients with type III adenomyosis is better than that of the other three types.

MP59-12 CAN ANATOMICAL MEASUREMENTS ON PREOPERATIVE PELVIC MAGNETIC RESONANCE IMAGING PREDICT POSTOPERATIVE URINARY INCONTINENCE AFTER HOLMIUM LASER ENUCLEATION OF THE PROSTATE?

You have accessJournal of UrologyCME1 Apr 2023MP59-12 CAN ANATOMICAL MEASUREMENTS ON PREOPERATIVE PELVIC MAGNETIC RESONANCE IMAGING PREDICT POSTOPERATIVE URINARY INCONTINENCE AFTER HOLMIUM LASER ENUCLEATION OF THE PROSTATE? Amir Khan, Ankur Choksi, Syed Rahman, Benjamin Press, Michael Jalfon, Mursal Gardezi, Tashzna Jones, Christopher Hayden, Eric Ghiraldi, Michael Siev, Gregory Lacy, Preston Sprenkle, and Daniel Kellner Amir KhanAmir Khan More articles by this author , Ankur ChoksiAnkur Choksi More articles by this author , Syed RahmanSyed Rahman More articles by this author , Benjamin PressBenjamin Press More articles by this author , Michael JalfonMichael Jalfon More articles by this author , Mursal GardeziMursal Gardezi More articles by this author , Tashzna JonesTashzna Jones More articles by this author , Christopher HaydenChristopher Hayden More articles by this author , Eric GhiraldiEric Ghiraldi More articles by this author , Michael SievMichael Siev More articles by this author , Gregory LacyGregory Lacy More articles by this author , Preston SprenklePreston Sprenkle More articles by this author , and Daniel KellnerDaniel Kellner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003312.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Anatomical dimensions of the prostate and membranous urethra have been associated with urinary incontinence after robotic prostatectomy. However, such measures have not been extensively studied with regards to urinary incontinence after holmium laser enucleation of the prostate (HoLEP). Our objective was to assess the impact of preoperative measurements of membranous urethral length (MUL), membranous urethral angle (MUA), levator ani thickness (LAT), and intravesical prostatic protrusion length (IPPL) and whether they can be utilized to predict early postoperative urinary incontinence after HoLEP. METHODS: We retrospectively reviewed our institutional HoLEP database for patients with available preoperative MRI pelvis/prostate from April 2019-June 2022. MRIs were analyzed for MUL (mm), MUA (degrees), LAT (mm), and IPPL (mm). Logistic regression analysis was performed defining urinary continence as <1 pad per day. Analysis was adjusted for age, body mass index, post-void residual, preoperative incontinence, and prostate-specific antigen (PSA). Separate analyses were performed using MUL, MUA, LAT, and IPPL. RESULTS: 128 patients were identified with preoperative MRIs that underwent HoLEP (Table 1). The median age was 69.3 (59.2-77.3) and median preoperative PSA of 5.9 (1.6-33.2). At 1 month, MUL, MUA, LAT, and IPPL were not found to be significantly associated with incontinence (p=0.31, 0.45, 0.27, and 0.86, respectively). Similarly, at 3 months, MUL, MUA, and LAT were not associated with incontinence (p=0.66, 0.42, 0.31, respectively). However, IPPL was found to be associated with urinary incontinence at 3 months (OR=1.09 [1.01-1.29] p=0.049). CONCLUSIONS: Preoperative measurement of IPPL is associated with postoperative urinary incontinence after HoLEP. Further anatomic features such as MUL, MUA, and LAT, which have been associated with incontinence after robotic prostatectomy, do not have an effect on postoperative incontinence after HoLEP in our study, suggesting such anatomical variations may play less of a role in postoperative incontinence. Further studies are needed to assess the impact of anatomical dimensions on surgical outcomes after HoLEP. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e812 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amir Khan More articles by this author Ankur Choksi More articles by this author Syed Rahman More articles by this author Benjamin Press More articles by this author Michael Jalfon More articles by this author Mursal Gardezi More articles by this author Tashzna Jones More articles by this author Christopher Hayden More articles by this author Eric Ghiraldi More articles by this author Michael Siev More articles by this author Gregory Lacy More articles by this author Preston Sprenkle More articles by this author Daniel Kellner More articles by this author Expand All Advertisement PDF downloadLoading ...

8761 Batwing Endometriosis: Radiographic Findings and Surgical Approach

<h3>Study Objective</h3> To present radiographic findings suggestive of deep infiltrating endometriosis of the uterosacral ligaments and posterior torus uterinus (referred to as batwing endometriosis) and review surgical considerations and approach to excision of disease. <h3>Design</h3> Description of imaging findings and surgical technique. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients with batwing endometriosis on preoperative pelvic magnetic resonance imaging (MRI) and concordant intraoperative findings. <h3>Interventions</h3> Preoperative pelvic MRI and laparoscopic or robotic excision of endometriosis with and without hysterectomy. <h3>Measurements and Main Results</h3> Batwing endometriosis can often be associated with an obliterated posterior cul-de-sac and present significant challenges during laparoscopy. Here we review a systematic approach to aid with restoration of this space and focus on relevant anatomy to consider. The following important steps are discussed: methods for navigating ureterolysis, ways to shave disease and preserve neurovascular and ligament support, and finally, techniques to consider with vaginal cuff closure for concurrent hysterectomy. In addition to highlighting batwing endometriosis on MRI, key pelvic structures are identified including the ureter, uterine vessels, and pararectal space which all aid in dissection. <h3>Conclusion</h3> Identification of batwing endometriosis on preoperative pelvic MRI may improve surgical planning. Knowledge of important anatomic considerations and surgical steps allows for safe and effective excision for patients with batwing endometriosis.

Intravoxel incoherent motion MRI for rectal cancer: correlation of diffusion and perfusion characteristics with clinical-pathologic factors.

Colorectal cancer is the most common cause of cancer-related death worldwide. Magnetic resonance imaging (MRI) has become a promising alternative method for staging the cancer. To evaluate parameters of intravoxel incoherent motion (IVIM) and their relationships with clinical-pathologic factors in rectal cancers. A total of 51 patients with histopathologically proven rectal cancer who underwent preoperative pelvic MRI were prospectively enrolled. Parameters (ADC, D, D*, and f) derived from IVIM-diffusion-weighted imaging (DWI) were independently measured by two radiologists. Student's t-test, receiver operating characteristic curves, and Spearman correlation were used for statistical analysis. ADC, D, and D* were significantly higher in pT1-2 tumors than in pT3-4 tumors (1.108 ± 0.233 vs. 0.950 ± 0.176, 0.796 ± 0.199 vs. 0.684 ± 0.114, 0.013 ± 0.005 vs. 0.008 ± 0.003, respectively; P < 0.05). D* exhibited a strong correlation with the tumor stage (r = -0.675, P < 0.001). In poorly differentiated cluster (PDC) grading, ADC, D*, and f were significantly lower in high-grade tumors than in low-grade tumors (0.905 ± 0.148 vs. 1.064 ± 0.200, 0.008 ± 0.002 vs. 0.011 ± 0.005, and 0.252 ± 0.032 vs. 0.348 ± 0.058, respectively; P < 0.05). The f value exhibited a significantly strong correlation with the PDC grades (r = -0.842, P < 0.001), and higher sensitivity and specificity (95.2% and 75.9%) than those shown by the ADC, D, and D* values. IVIM parameters, especially f, demonstrated a strong correlation with histologic grades and showed a better performance in differentiating between high- and low-grade rectal cancers. These parameters would be helpful in predicting tumor aggressiveness and prognosis.

Estimated Levator Ani Subtended Volume: A Predictive Biomarker for Surgical Outcomes Following Native Tissue Apical Repair

The aim of the study was to investigate the clinical utility of estimated levator ani subtended volume (eLASV) as a prospective preoperative biomarker for prediction of surgical outcomes. This is a prospective case-control pilot study. Patients were recruited and gave consent between January 2018 and December 2020. Surgical failure was defined by composite score. The eLASV was calculated for each patient based on a previously published algorithm. Descriptive statistics, Fisher exact test, log-binomial regression, area under a receiver operating characteristics, Bland-Altman plot, Lin coefficient, and κ coefficient were all performed for analysis. Fifty-one patients gave consent, 31 completed preoperative magnetic resonance imaging, 27 underwent surgery (uterosacral ligament suspension), and 19 followed up for 1-year examination. Five patients (26.3%) were defined as surgical failure with median eLASV volume of 57.0 (interquartile range, 50.1-66.2). Fourteen patients (73.7%) were defined as surgical success with median eLASV of 28.2 (interquartile range, 17.2-24.3). Eighty percent of the surgical failure group (4/5) had elevated volume of eLASV, where only 14.3% of the success group (2/14) had an elevated volume (P = 0.0173). No confounders were found and unadjusted log-binomial regression suggested that patients with a high eLASV were 8.7 (95% confidence interval, 1.2-61.9) times more likely to experience surgical failure compared with those with low eLASV. The c-statistic (area under a receiver operating characteristics) was high at 0.829 along with Lin concordance coefficient of 0.949 (95% confidence interval, 0.891-0.977) for continuous data between the 2 interrater observer teams. In this small prospective pilot study, patients with elevated eLASV on a preoperative pelvic magnetic resonance imaging were associated with an increased risk for surgical failure at 1 year regardless of age, body mass index, stage, or parity.CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT03534830.

An Application of Machine Learning That Uses the Magnetic Resonance Imaging Metric, Mean Apparent Diffusion Coefficient, to Differentiate between the Histological Types of Ovarian Cancer.

This retrospective single-center study included patients diagnosed with epithelial ovarian cancer (EOC) using preoperative pelvic magnetic resonance imaging (MRI). The apparent diffusion coefficient (ADC) of the axial MRI maps that included the largest solid portion of the ovarian mass was analysed. The mean ADC values (ADCmean) were derived from the regions of interest (ROIs) of each largest solid portion. Logistic regression and three types of machine learning (ML) applications were used to analyse the ADCs and clinical factors. Of the 200 patients, 103 had high-grade serous ovarian cancer (HGSOC), and 97 had non-HGSOC (endometrioid carcinoma, clear cell carcinoma, mucinous carcinoma, and low-grade serous ovarian cancer). The median ADCmean of patients with HGSOC was significantly lower than that of patients without HGSOCs. Low ADCmean and CA 19-9 levels were independent predictors for HGSOC over non-HGSOC. Compared to stage I disease, stage III disease was associated with HGSOC. Gradient boosting machine and extreme gradient boosting machine showed the highest accuracy in distinguishing between the histological findings of HGSOC versus non-HGSOC and between the five histological types of EOC. In conclusion, ADCmean, disease stage at diagnosis, and CA 19-9 level were significant factors for differentiating between EOC histological types.

High-Intensity vs Low-Intensity Knowledge Translation Interventions for Surgeons and Their Association With Process and Outcome Measures Among Patients Undergoing Rectal Cancer Surgery

Surgeon-directed knowledge translation (KT) interventions for rectal cancer surgery are designed to improve patient measures, such as rates of permanent colostomy and in-hospital mortality, and to improve survival. To evaluate the association of sustained, iterative, integrated KT rectal cancer surgery interventions directed at all surgeons with process and outcome measures among patients undergoing rectal cancer surgery in a geographic region. This quality improvement study used administrative data from patients who underwent rectal cancer surgery from April 1, 2004, to March 31, 2015, in 14 health regions in Ontario, Canada. Follow-up was completed on March 31, 2020. Surgeons in 2 regions were offered intensive KT interventions, including annual workshops, audit and feedback sessions, and, in 1 of the 2 regions, operative demonstrations, from 2006 to 2012 (high-intensity KT group). Surgeons in the remaining 12 regions did not receive these interventions (low-intensity KT group). Among patients undergoing rectal cancer surgery, proportions of preoperative pelvic magnetic resonance imaging (MRI), preoperative radiotherapy, and type of surgery were evaluated, as were in-hospital mortality and overall survival. Logistic regression models with an interaction term between group and year were used to assess whether process measures and in-hospital mortality differed between groups over time. A total of 15 683 patients were included in the analysis (10 052 [64.1%] male; mean [SD] age, 65.9 [12.1] years), of whom 3762 (24.0%) were in the high-intensity group (2459 [65.4%] male; mean [SD] age, 66.4 [12.0] years) and 11 921 (76.0%) were in the low-intensity KT group (7593 [63.7%] male; mean [SD] age, 65.7 [12.1] years). A total of 1624 patients (43.2%) in the high-intensity group and 4774 (40.0%) in the low-intensity KT group underwent preoperative MRI (P < .001); 1321 (35.1%) and 4424 (37.1%), respectively, received preoperative radiotherapy (P = .03); and 967 (25.7%) and 2365 (19.8%), respectively, received permanent stoma (P < .001). In-hospital mortality was 1.6% (59 deaths) in the high-intensity KT group and 2.2% (258 deaths) in the low-intensity KT group (P = .02). Differences remained significant in multivariable models only for permanent stoma (odds ratio [OR], 1.67; 95% CI, 1.24-2.24; P < .001) and in-hospital mortality (OR, 0.67; 95% CI, 0.51-0.87; P = .003). In both groups over time, significant increases in the proportion of patients undergoing preoperative MRI (from 6.3% to 67.1%) and preoperative radiotherapy (from 16.5% to 44.7%) occurred, but there were no significant changes for permanent stoma (25.4% to 25.3% in the high-intensity group and 20.0% to 18.3% in the low-intensity group) and in-hospital mortality (0.8% to 0.8% in the high-intensity group and 2.2% to 1.8% in the low-intensity group). Time trends were similar between groups for measures that did or did not change over time. Patient overall survival was similar between groups (hazard ratio, 1.00; 95% CI, 0.90-1.11; P = .99). In this quality improvement study, between-group differences were found in only 2 measures (permanent stoma and in-hospital mortality), but these differences were stable over time. High-intensity KT group interventions were not associated with improved patient measures and outcomes. Proper evaluation of KT or quality improvement interventions may help avoid opportunity costs associated with ineffective strategies.

Predictive factors of pathological complete response after neoadjuvant chemoradiotherapy for middle-low rectal cancer

Objective: To explore the predictive factors of pathological complete response (pCR) after neoadjuvant chemoradiotherapy for middle-low rectal cancer. Methods: A case-control study was conducted. The inclusion criteria were as follows: (1) colonoscopy, digital examination or magnetic resonance imaging (MRI) showed a distance from the lower edge of the tumor to the dentate line of no more than 10 cm; (2) complete clinicopathological data were available; (3) preoperative biopsy revealed adenocarcinoma; (4) preoperative pelvic MRI or endorectal ultrasonography was performed; (5) no distant metastasis was found. Exclusion criteria: (1) preoperative radiotherapy and chemotherapy were not administrated according to the standard; (2) simultaneous multiple primary cancer and familial adenomatous polyposis were observed. According to the above criteria, clinicopathological data of 245 patients with middle-low rectal cancer undergoing preoperative neoadjuvant chemoradiotherapy in Changhai Hospital of Navy Medical University from January 2012 to December 2019 were retrospectively collected. Univariate analysis and multivariate logistic analysis were used to identify the clinical factors predicting pCR. pCR is defined as complete disappearance of cancer cells under the microscope in cancer specimens (including lymph nodes) after neoadjuvant chemoradiotherapy. Results: A total of 72 patients with pCR were enrolled in this study. Univariate analysis showed that preoperative T stage, tumor circumference, tumor morphology, carbohydrate antigen (CA) 19-9, interval between the end of neoadjuvant therapy and operation were associated with pCR (all P<0.05). The above 5 variables were included in multivariate logistic analysis and the results revealed that the T stage (OR=5.743, 95% CI: 2.416-13.648, P<0.001), tumor circumference (OR=7.754, 95% CI: 3.822-15.733, P<0.001), tumor morphology (OR=0.264, 95% CI: 0.089-0.786, P=0.017) and the interval between the end of neoadjuvant therapy and operation (OR=0.303, 95% CI: 0.147-0.625, P=0.001) were independent predictive factors of pCR, while CA 19-9 level was not an independent factor (OR=1.873, 95% CI:0.372-9.436, P=0.447). Conclusion: By knowing the clinical features of preoperative T stage, tumor circumference, tumor morphology and the interval between neoadjuvant chemoradiotherapy and operation, patients with higher likelyhood of pCR after neoadjuvant chemoradiotherapy may be identified.

Magnetic resonance imaging findings of carcinoma arising from anal fistula: A retrospective study in a single institution.

BACKGROUNDMagnetic resonance imaging (MRI) is currently the standard investigation for suspected perianal diseases. Carcinoma arising from anal fistula is very rare, and early diagnosis is often difficult.AIMTo describe and summarize the MRI findings of carcinoma arising from anal fistula.METHODSIn this retrospective study, records of ten patients diagnosed with carcinoma arising from anal fistula and confirmed by surgery (n = 7) or biopsy (n = 3) between June 2006 and August 2018 were analyzed. All patients underwent preoperative pelvic MRI. Morphologic features, signal characteristics, fistula between the mass and the anus, contrast enhancement of mass, signal and enhancement of peritumoral areas, and regional lymphadenopathy were assessed.RESULTSAll ten tumors were solitary (8 mucinous adenocarcinomas and 2 adenocarcinomas). The maximum diameter of the tumors ranged from 3.4 cm to 12.4 cm (median: 4.15 cm; mean: 5.68 cm). Eight patients had a fistula between the mass and the anus. Contrast enhancement of the peritumoral areas was noted in three (3/5) patients. Perirectal or inguinal lymphadenopathy was noted in seven patients. Most lesions of mucinous adenocarcinoma were multiloculated and cauliflower-like, with a thin capsule and focally unclear boundary. They were markedly hyperintense on fat-suppressed T2WI, slightly hyperintense with focal hyperintensity on diffusion-weighted imaging (DWI), and hyperintense with focal hypointensity on apparent diffusion coefficient (ADC) map, with progressive mesh-like contrast enhancement. Adenocarcinomas had an infiltrative margin without a capsule and appeared heterogeneously hyperintense or slightly hyperintense on fat-suppressed T2WI, hyperintense on DWI, and hypointense on ADC map, with persistent heterogeneous enhancement.CONCLUSIONOur study highlighted several characteristic and potentially helpful MRI findings to diagnose carcinomas arising from anal fistula.

Rectal Prolapse After Laparoscopically Assisted Anorectoplasty for Anorectal Malformations.

Aim: To clarify the characteristics of patients with rectal prolapse after laparoscopically assisted anorectoplasty (LAARP), estimate the causes, and evaluate its impact on postoperative bowel function. Methods: The medical records of patients who underwent LAARP for high- or intermediate-type anorectal malformation between 2000 and 2019 were retrospectively reviewed. Clinical data were compared between patients with (Group P) and without prolapse (normal, Group N). Fecal continence was evaluated using the clinical assessment score for fecal continence developed by the Japanese Study Group of Anorectal Anomalies. For patients who underwent pelvic magnetic resonance imaging (MRI) before LAARP, atrophy, or asymmetry of the anal sphincter and levator ani was evaluated by a radiologist. Results: Of the 49 patients, 29 (59%) had rectal prolapse after LAARP (Group P) and 20 did not (Group N). We found no significant difference in gender, type of malformations, incidence of associated spinal or lumbosacral anomalies, procedure time, and postoperative bowel function at ages 4, 8, 12, and 16 years. However, LAARP was performed significantly earlier in Group N (median [range], 180 [123-498] days) than in Group P (210 [141-570] days). In Group P, 18 patients (62%) developed prolapse before colostomy takedown. Eight of 26 patients who underwent surgical prolapse repair required redo procedures. Twenty-five patients who underwent preoperative pelvic MRI showed no significant relationship between the muscular abnormalities and the incidence of postoperative rectal prolapse. Conclusions: Although recurrence is common, performing LAARP at a younger age might prevent postoperative prolapse development.

Post Prostatectomy Pathologic Findings of Patients With Clinically Significant Prostate Cancer and no Significant PI-RADS Lesions on Preoperative Magnetic Resonance Imaging

ObjectivesWe present postprostatectomy pathology results from a series of prostate cancer (Pca) Gleason grade group ≥2 patients who did not have findings suggestive of cancer on preoperative pelvic magnetic resonance imaging (MRI). MethodsWe performed an institutional retrospective study of prostate magnetic resonance imaging (MRI) examinations done from October 2015 to February 2018. We identified patients who underwent prostatectomy for Pca Gleason ≥3 + 4 diagnosed on prostate biopsy with no associated MRI findings suggestive of malignancy and analyzed their postprostatectomy pathologic findings and MRI imaging results. ResultsAt our institution, 850 men with Pca received MRI between 2015 and 2018, and 156/850 patients received robotic-assisted radical prostatectomy. Thirty-three patients (33/156 = 21%) had negative MRI for PIRAD 3 or greater but had a biopsy showing significant Pca. Their mean (range) age was 62.7 (50-86) years. Their median (interquartile range) PSA, and PSA density were, 4.6 (3.7) ng/mL and 0.12 (0.05) ng/mL/cm2, respectively; all not significantly different from patients with visible lesions on MRI who underwent surgery. On post prostatectomy pathology, 27/33 (82%) men had Pca Gleason score 7 or greater. The most common pattern was infiltrative growth with cancer glands intermingling between benign glands. ConclusionWe describe the pathologic and imaging findings in an extensive series of men with clinically significant Pca with no significant lesions on preoperative MRI. Our results support the importance of patient counseling on the risk of missing significant Pca on MRI in isolation from other clinical variables.

MP70-15 PRECISE PROSTATE CRYOTHERAPY GUIDED BY MAGNETIC RESONANCE IMAGING AND 99MTC-PSMA SPECT/CT

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy II (MP70)1 Apr 2020MP70-15 PRECISE PROSTATE CRYOTHERAPY GUIDED BY MAGNETIC RESONANCE IMAGING AND 99MTC-PSMA SPECT/CT Guo-Wen Lin* Guo-Wen Lin*Guo-Wen Lin* More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000950.015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate cryotherapy can effectively control tumor lesions, relieve symptoms and improve patients' quality of life by killing tumor cells at low temperature. The 99mTc-PSMA SPECT/CT examination has high specificity, sensitivity and cost performance for prostate cancer. This study explored the value of precision magnetic resonance imaging and 99mTc-PSMA SPECT/CT guided precision prostate cryotherapy in early localized prostate cancer. METHODS: We retrospectively collected data from 20 patients with localized prostate cancer who underwent prostate cryotherapy from October 2017 to October 2018. Preoperative pelvic magnetic resonance imaging (MR) and 99mTc-PSMA SPECT/CT were performed to assess the location of lesions and its size. Argon-helium cryoablation technique was used. The intraoperative ultrasound guided the 1.47mm diameter probe into the prostate through the perineum. The argon gas formed the needle tip into a spherical ice hockey with a diameter of 2cm and the ice hockey cooled to -140∼-170°C, after 10-15 minutes, the argon gas was turned off, and then the helium gas was started to rapidly raise the local temperature to 20∼40°C for 3 minutes, and two cycles were performed to completely damage the diseased tissue. Postoperative follow-up was used to assess changes in PSA and imaging. RESULTS: Evaluation of lesions using images, combined with intraoperative ultrasound real-time images. All patients accurately located the lesion location and size, and ice hockey range prostate tissue should be included as much as possible, and at least 1 needle complete including tumor lesions. PSA was reviewed 1 month after cryotherapy, suggesting that the median value was 10.3 ng/mL (45.5% reduction). Three months later, 18 patients underwent MR and/or 99mTc-PSMA SPECT/CT, showing the lesion disappeared completely for 4 cases, 14 patients' local lesions were clearly controlled. Common postoperative adverse reactions included short-term dysuria (6/20, 30%), lower abdominal distension (4/20, 20%), hematuria (1/20, 5%), and local necrosis of the urethra (1/20, 5%). CONCLUSIONS: Prostatic cryotherapy is effective for patients with a life expectancy of <10 years or an early stage of surgery that is not suitable for surgery. The examination of MR and/or 99mTc-PSMA SPECT/CT can guide the precise positioning and treatment of prostate cryopreservation, and has great clinical value. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1060-e1061 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Guo-Wen Lin* More articles by this author Expand All Advertisement PDF downloadLoading ...

Performances de l’IRM dans le bilan d’extension locale préopératoire des cancers de l’endomètre : l’expérience nantaise

ObjectivesTo determine the diagnostic accuracy of magnetic resonance imaging (MRI) for local preoperative staging in endometrial cancer in our center (Centre Hospitalier Universitaire de Nantes: CHU), since the French National Cancer Institute's surgery recommendations publication in 2010, especially for the prediction of myometrial and cervical stromal invasion. MethodsRetrospective monocentric study of consecutive women operated of endometrial cancer in gynecology department of CHU de Nantes, who underwent preoperative pelvic MRI in our Radiology department from November 2010 to November 2016. MRI data collected from initial report and compared to surgical histological findings as gold standard. ResultsSixty-four patients were included. Deep myometrial invasion was present in 35 patients in MRI versus 34 patients on postoperative histology (5 false positives, 4 false negatives). Cervical stromal invasion was present in 9 patients in MRI versus 19 patients on postoperative histology (2 false positives, 12 false negatives). The sensitivity and the specificity were respectively 88.23% (95% confidence intervals (CI) [0.71–0.96]) and 83.33% (CI [0.64–0.93]) for the deep myometrial invasion; 36.84% (CI [0.17–0.61]) and 95.55% (CI [0.83–0.99]) for the cervical stromal invasion. ConclusionOur results were comparable to the literature data, with a low sensitivity for the cervical stromal invasion detection, driving us to change our MRI protocol with optional high-resolution T2 sequences perpendicular to the cervical canal if necessary.

Deep infiltrating endometriosis: Can magnetic resonance imaging anticipate the need for colorectal surgeon intervention?

ObjectiveTo identify magnetic resonance imaging (MRI) features associated with colorectal surgical bowel resection for treatment of deep infiltrating endometriosis (DIE). Materials and methods122 preoperative pelvic MRIs in women with laparoscopically-proven DIE and subsequent surgery (2006–2015) were identified, and retrospective cohort analysis performed. MRIs were reviewed independently by two radiologists blinded to surgical/histopathological outcomes. Associations between MRI characteristics of middle/posterior compartment endometriosis and surgical outcomes were investigated to identify MRI features associated with colorectal surgical bowel resection. ResultsMRI features associated with colorectal surgical intervention were: presence of an MRI bowel lesion (sensitivity 95.3%, specificity 63.3%, ROC-AUC 0.79); MRI bowel lesions ≥20 mm in length (sensitivity 91%, specificity 77%, ROC-AUC 0.84); MRI bowel lesions invading the muscularis or submucosa/mucosa layers (sensitivity 95.3%, specificity 63.3%, ROC-AUC 0.90). ConclusionThis study identifies MRI features that have potential diagnostic utility in identifying the need for colorectal surgical intervention in patients with DIE.

1603 Fibroid Mapping with MRI to Optimize Surgical Planning

Video Objective This video discusses the use of preoperative Magnetic Resonance Imaging (MRI) to optimize surgical planning of laparoscopic myomectomies in patients with multiple fibroids desiring future fertility. Setting University hospital that serves as a referral center for patients desiring myomectomies. We will present two patients with multiple fibroids and infertility who elected to undergo surgical intervention. MRI's were obtained and we will highlight the use of imaging to assist in the surgical planning of the myomectomy procedure. Interventions For both patients, preoperative pelvic MRI (with and without contrast) was performed. Multiple fibroids were found and T2 images in 3 planes were used to map fibroid location in relation to key anatomical structures (Endometrium, cornua, cervix, etc). This critical information allows for efficient intra-operative management and resection of fibroids reducing the risk of recurrence. Anticipating endometrial involvement may allow for resection without compromising the integrity of the endometrial cavity which could have a significant impact on fertility and mode of delivery. Conclusion In the setting of 4 or more fibroids, MRI is likely superior to ultrasound for the purposes of preoperative planning. Mapping techniques helps surgeons plan efficient resection of the pathology to optimize surgical outcomes.

Cost-effectiveness of a preoperative pelvic MRI in pelvic organ prolapse surgery.

To investigate the cost-effectiveness of preoperative pelvic magnetic resonance imaging (MRI) in identifying women at high risk of surgical failure following apical repair for pelvic organ prolapse (POP). A decision tree (TreeAgePro Healthcare software) was designed to compare outcomes and costs of screening with a pelvic MRI versus no screening. For the strategy with MRI, expected surgical outcomes were based on a calculated value of the estimated levator ani subtended volume (eLASV) from previously published work. For the alternative strategy of no MRI, estimates for surgical outcomes were obtained from the published literature. Costs for surgical procedures were estimated using the 2008-2014 National Inpatient Sample (NIS). A cost-effectiveness analysis from a third-party payer perspective was performed with the primary measure of effectiveness defined as avoidance of surgical failure. Deterministic and probabilistic sensitivity analyses were performed to assess how robust the calculated incremental cost-effectiveness ratio was to uncertainty in decision tree estimates and across a range of willingness-to-pay values. A preoperative MRI resulted in a 17% increased chance of successful initial surgery (87% vs. 70%) and a decreased risk of repeat surgery with an ICER of $2298 per avoided cost of surgical failure. When applied to annual expected women undergoing POP surgery, routine screening with preoperative pelvic MRI costs $90 million more, but could avoid 39,150 surgical failures. The use of routine preoperative pelvic MRI appears to be cost-effective when employed to identify women at high risk of surgical failure following apical repair for pelvic organ prolapse.

Impact of pelvic MRI in routine clinical practice on staging of IB1-IIA2 cervical cancer.

Purpose: To evaluate the impact of pelvic magnetic resonance imaging (MRI) on staging of IB1–IIA2 cervical cancer in routine clinical practice.Patients and Methods: A total of 1,016 patients with IB1-IIA2 cervical cancer who underwent primary surgery and preoperative pelvic MRI between January 2009 and December 2015 were identified in a retrospective multicentre study. Data on clinical stage, MRI reports and surgicopathologic findings were extracted from medical records. The impact of MRI on clinical staging was evaluated by comparison before and after combination of MRI. Using surgicopathologic findings as the reference standard, the impact of pelvic MRI on the accuracy of clinical staging was evaluated. Furthermore, the impact on the accuracy of individual staging parameters such as maximal tumor diameter, vaginal involvement or parametrial infiltration were also evaluated.Results: After combination of pelvic MRI, clinical stage remained unchanged in 59.7%, upstaged in 17.2%, and downstaged in 23.0% of the patients. The overall accuracy of clinical staging increased from 61.0% to 81.4% in our study (P<0.05). As for individual staging parameters, the area under the curve (AUC) for maximal tumor diameter increased from 0.58 to 0.81 (P<0.05). However, the AUC for vaginal involvement decreased from 0.61 to 0.57 (P>0.05). The AUC for parametrial infiltration was also suboptimal (AUC=0.56, P<0.05).Conclusion: In routine clinical practice, MRI could increase the overall accuracy of clinical staging in IB1–IIA2 cervical cancer. For staging parameters, it only significantly increased the accuracy of maximal tumor diameter.