Suspicious Foci Research Articles

What approach should we take for the incidental finding of increased 18F-FDG uptake foci in the colon on PET/CT?

F-Fluorodeoxyglucose (F-FDG) PET/CT represents an imaging modality that is gaining increasingly more prominence in screening, staging, and therapeutic monitoring of malignant diseases. An incidental focus of uptake in different regions of the body is not an uncommon finding during PET/CT imaging. Patients with incidental gastrointestinal tract findings comprise ∼3% of the overall patient group. The aim of the current study was to provide contributory information in relation to the answer on the most appropriate approach in cases with incidental colonic F-FDG uptake. A retrospective examination was performed on PET/CT results of 5258 patients. Of these, 152 were recommended to undergo colonoscopy because of the presence of suspicious foci and 31 underwent colonoscopy within 60 days with biopsy from all visible lesions. These dates were also examined. Of the 24 patients undergoing colonoscopy with a suspicion of malignancy, five (20.83%) had no pathological findings. Of the 19 (79.17%) cases with a pathological finding in endoscopy, histopathology showed a benign lesion in five (20.83%), premalignant lesion in seven (29.17%), and a malignant lesion in seven (29.17%). Among seven patients undergoing colonoscopy because of a suspicion of inflammatory bowel disease, five were free of pathological signs and two patients with pathological endoscopy findings had nonspecific inflammation as documented by histopathological examination. Colonoscopic and histopathological examination of the increased foci of colonic F-FDG uptake incidentally detected at PET/CT seems to be a plausible approach.

Can multiparametric MRI rule in or rule out significant prostate cancer?

To show how multiparametric MRI can rule in the presence of significant prostate cancer (PCa), allowing for magnetic resonance-targeted biopsies to detect aggressive tumors eligible for immediate treatment and to evaluate if mp-MRI can rule out significant tumor foci to avoid overdiagnosis and overtreatment of PCa. Diffusion-weighted MRI plays a major role to detect tumor foci and to rule in significant PCa. A low apparent diffusion coefficient (ADC) value indicates that high Gleason grade tumors are present. Conversely, the absence of any suspicious focus or foci with a high apparent diffusion coefficient value indicates either benign tissue or low-grade tumor mp-MRI Multiparametric MRI is a highly accurate filter to detect aggressive tumors and to avoid detection of insignificant cancer. There is growing evidence that it may be indicated in any man with an elevated Prostatic Specific Antigen level before considering whether an immediate biopsy should be performed or whether a simple follow-up should be the option.

Detecting metastatic prostate carcinoma in pelvic lymph nodes following neoadjuvant hormone therapy: the eyes have it!

Residual cancer morphology in radical prostatectomies (RPs) after neoadjuvant hormone therapy includes inconspicuous cytology, and treated tumour cells can be difficult to identify in lymph nodes. The aim of this study was to evaluate the role of immunohistochemistry (IHC) in identifying occult lymph node metastases following neoadjuvant hormone treatment of prostate cancer. One hundred and twenty-eight lymph nodes from 24 patients treated with neoadjuvant hormone therapy, including abiraterone acetate alone or combined with leuprolide, were stained with antibodies against keratin AE1/AE3, prostate-specific antigen (PSA), prostate-specific acid phosphatase (PrAP), androgen receptor (AR), and NKX3.1. IHC slides were scored 'blind', and then retrospectively compared with haematoxylin and eosin (H&E)-stained slides and pathology reports. IHC identified carcinoma in six lymph nodes from three patients. All metastases were positive for NKX3.1 and AR, five of six were positive for AE1/AE3, and three of six were positive for PSA; PrAP was negative in all metastatic foci. All six lymph node metastases had been identified by H&E staining at the time of RP. These findings suggest that routine use of IHC on lymph nodes from neoadjuvant-treated prostate carcinomas is not necessary. Nevertheless, for suspicious small foci of atypical cells in neoadjuvant-treated lymph nodes, NKX3.1 and AR appear to have the greatest sensitivity.

Augmenting MRI-transrectal ultrasound-guided prostate biopsy with temporal ultrasound data: a clinical feasibility study.

In recent years, fusion of multi-parametric MRI (mp-MRI) with transrectal ultrasound (TRUS)-guided biopsy has enabled targeted prostate biopsy with improved cancer yield. Target identification is solely based on information from mp-MRI, which is subsequently transferred to the subject coordinates through an image registration approach. mp-MRI has shown to be highly sensitive to detect higher-grade prostate cancer, but suffers from a high rate of false positives for lower-grade cancer, leading to unnecessary biopsies. This paper utilizes a machine-learning framework to further improve the sensitivity of targeted biopsy through analyzing temporal ultrasound data backscattered from the prostate tissue. Temporal ultrasound data were acquired during targeted fusion prostate biopsy from suspicious cancer foci identified in mp-MRI. Several spectral features, representing the signature of backscattered signal from the tissue, were extracted from the temporal ultrasound data. A supervised support vector machine classification model was trained to relate the features to the result of histopathology analysis of biopsy cores obtained from cancer foci. The model was used to predict the label of biopsy cores for mp-MRI-identified targets in an independent group of subjects. Training of the classier was performed on data obtained from 35 biopsy cores. A fivefold cross-validation strategy was utilized to examine the consistency of the selected features from temporal ultrasound data, where we achieved the classification accuracy and area under receiver operating characteristic curve of 94 % and 0.98, respectively. Subsequently, an independent group of 25 biopsy cores was used for validation of the model, in which mp-MRI had identified suspicious cancer foci. Using the trained model, we predicted the tissue pathology using temporal ultrasound data: 16 out of 17 benign cores, as well as all three higher-grade cancer cores, were correctly identified. The results show that temporal analysis of ultrasound data is potentially an effective approach to complement mp-MRI-TRUS-guided prostate cancer biopsy, specially to reduce the number of unnecessary biopsies and to reliably identify higher-grade cancers.

Prostate Imaging Reporting and Data System and Likert Scoring System: Multiparametric MR Imaging Validation Study to Screen Patients for Initial Biopsy.

To compare the diagnostic performance of the magnetic resonance (MR) imaging-based Prostate Imaging Reporting and Data System (PI-RADS) and a Likert scale in the detection of prostate cancer in a cohort of patients undergoing initial prostate biopsy. This institutional review board-approved two-center prospective study included 118 patients with normal digital rectal examination (DRE) results but elevated prostate-specific antigen (PSA) levels (4-20 ng/mL) who were referred for initial prostate biopsies and had one suspicious (Likert scale score, ≥3) focus at prebiopsy 1.5-T multiparametric MR imaging performed with T2-weighted, diffusion-weighted [DW], and dynamic contrast material-enhanced imaging. Targeted core biopsies and random systematic core biopsies were performed. The elementary unit for analysis was the core. Relationships were assessed by using the Mann-Whitney U test. Yates corrected and Pearson χ(2) tests were used to evaluate categoric variables. A training set was randomly drawn to construct the receiver operating characteristic curves for the summed PI-RADS scores and for the Likert scale scores. The thresholds to recommend biopsy were obtained from the Youden J statistics and were tested in the remaining validation set in terms of predictive characteristics. Interobserver variability was analyzed by using weighed κ statistics in a random set of 50 patients. Higher T2-weighted, DW, and dynamic contrast-enhanced imaging PI-RADS scores were observed in areas that yielded cancer-positive cores. The percentage of positive cores increased with the sum of scores aggregated in five classes as follows: For summed PI-RADS scores of 3-5, the percentage of positive cores was 2.3%; for scores of 6-8, it was 5.8%; for scores of 9 or 10, it was 24.7%; for scores of 11 or 12, it was 51.8%; and for scores of 13-15, it was 72.1% (P for trend, <.0001). For the threshold of summed PI-RADS scores of 9 or greater, sensitivity was 86.6%, specificity was 82.4%, the positive predictive value was 52.4%, the negative predictive value was 96.5%, and accuracy was 83.2%. The respective data for Likert scale scores of 3 or greater were 93.8%, 73.6%, 44.3%, 98.1%, and 73.3%. Good interobserver agreement was observed for the Likert scale (κ = 0.80) and the summed PI-RADS (κ = 0.73) scoring systems. PI-RADS provided the site-specific stratified risk of cancer-positive cores in biopsy-naive men with normal DRE results and elevated PSA levels. There was no significant difference between summed PI-RADS scores of 9 or greater and Likert scale scores of 3 or greater in the detection of cancer in the peripheral zone.

PPV3 of Suspicious Breast MRI Findings

Magnetic resonance imaging (MRI) characteristics of Breast Imaging Reporting and Data System (BI-RADS) 4 and 5 lesions were evaluated to identify characteristics that may improve the positive predictive value (PPV) of a biopsy. MRI BI-RADS 4 or 5 breast findings in 101 women who underwent biopsy leading to a diagnosis of cancer within 1 year (PPV3; n=115 cases) were reviewed. Patient history, lesion morphology, enhancement pattern and kinetics, and T2 characteristics were examined. The PPV3 of all BI-RADS 4 and 5 breast lesions seen on MRI was 22.6% (26 of 115). Excluding lesions with second-look imaging correlates decreased the PPV3 to 11.8% (6/51). Of the MRI-guided biopsies, 20.9% (24 of 115) yielded a high-risk lesion, altering surgical management. MRI lesion type did not significantly affect the PPV3: the PPV3 was 26.3% (15 of 57) for masses, 21.4% (9 of 42) for non mass enhancement (NME) and 12.5% (2 of 16) for suspicious foci. The PPV3 for lesions found on diagnostic MRI in women with newly diagnosed cancer was 30.8% (20 of 65) which was statistically significantly greater compared to a PPV3 of 11.9% (5 of 42) for lesions identified on high-risk screening MRI. Suspicious MRI findings identified on a second-look examination are more likely malignant than those seen only on MRI. Suspicious MRI findings discovered in patients with concurrent malignancy have a greater PPV3 than those detected on high-risk screening MRIs. However, the type of MRI finding (mass vs. NME vs. foci) does not significantly affect the PPV3 and should not be used as a discriminator for determining biopsy threshold.

Osteolytic metastasis detected in a patient with lung carcinoma by F18-FDG PET

We present a 53-year-old man with a vocal cord paralysis observed as a primary manifestation of lung carcinoma. Tc-99m MDP whole body bone scan was performed and resulted in a normal scintiscan. The bone scan did not reveal any suspicious foci of uptake. The possibility of bone metastasis was taken into consideration. A whole body F18-FDG-PET scan showed intense uptake in the left upper lung corresponding to the primary tumor. A bronchial biopsy confirmed infiltration by small cell lung carcinoma (SCLC). SCLC is composed of poorly differentiated, rapidly growing cells with diseases usually occurring centrally rather than peripherally. It metastasizes early. The whole-body F18-FDG-PET scan clearly demonstrated a focus of increased uptake in the second lumbar vertebral body suspicious for osteolytic metastasis. A lytic bone metastasis was confirmed by MRI. The patient then received therapy and underwent follow up abdominal CT. The scan showed blastic changes in the L2 vertebra suggesting response to treatment.

Diagnostic utility of p63 and α-methyl acyl Co A racemase in resolving suspicious foci in prostatic needle biopsy and transurethral resection of prostate specimens.

The objective is to assess the utility of the p63 and α-methylacyl CoA racemase (AMACR) in resolving suspicious foci in prostatic needle biopsy and transurethral resection of prostate (TURP) specimens. A total of 470 cases are selected. These included 310 TURP specimens, 157 needle biopsies and 03 radical prostatectomy specimens. All the cases are reviewed and divided into three categories. Benign (370), cases with suspicious foci (40 cases) and malignant (60 cases). Immunohistochemistry (IHC) was carried out using monoclonal AMACR and p63 antibodies in the 40 suspicious cases along with positive and negative controls. This study showed AMACR had a sensitivity of 95%, specificity of 92.5%, whereas p63 had a sensitivity of 90%, specificity of 100%. All the 40 suspicious cases were resolved using a combination of morphology and IHC expression p63 and AMACR. In 13 (32.5%), of the 40 suspicious cases there was change of diagnosis based of morphology, clinical details and staining with p63 and AMACR, In the 11 cases (11/40), diagnosis was changed from the benign to malignant. In one case benign to high grade prostatic intraepithelial neoplasia (1/40) and in one case from malignant to benign (1/40). This change was statistically significant with P value of 0.013. Combination of p63 and AMACR is of great additional value in combating the morphologically suspicious cases and should be used on case to case basis especially in prostatic needle biopsies and small foci lesions.

Pilot study of a novel tool for input-free automated identification of transition zone prostate tumors using T2- and diffusion-weighted signal and textural features

To present results of a pilot study to develop software that identifies regions suspicious for prostate transition zone (TZ) tumor, free of user input. Eight patients with TZ tumors were used to develop the model by training a Naïve Bayes classifier to detect tumors based on selection of most accurate predictors among various signal and textural features on T2-weighted imaging (T2WI) and apparent diffusion coefficient (ADC) maps. Features tested as inputs were: average signal, signal standard deviation, energy, contrast, correlation, homogeneity and entropy (all defined on T2WI); and average ADC. A forward selection scheme was used on the remaining 20% of training set supervoxels to identify important inputs. The trained model was tested on a different set of ten patients, half with TZ tumors. In training cases, the software tiled the TZ with 4 × 4-voxel "supervoxels," 80% of which were used to train the classifier. Each of 100 iterations selected T2WI energy and average ADC, which therefore were deemed the optimal model input. The two-feature model was applied blindly to the separate set of test patients, again without operator input of suspicious foci. The software correctly predicted presence or absence of TZ tumor in all test patients. Furthermore, locations of predicted tumors corresponded spatially with locations of biopsies that had confirmed their presence. Preliminary findings suggest that this tool has potential to accurately predict TZ tumor presence and location, without operator input.

Prostate Cancer: Comparison of Dynamic Contrast-Enhanced MRI Techniques for Localization of Peripheral Zone Tumor

The objective of this study was to compare the performance of different methodologies for interpretation of dynamic contrast-enhanced MRI (DCE-MRI) in localization of peripheral zone prostate cancer. Forty-three men (mean age, 59±8 years) with biopsy-proven prostate cancer who underwent prostate MRI including DCE-MRI before prostatectomy were included. Two observers independently reviewed DCE-MRI data using three methodologies: qualitative, in which kinetic curves of signal intensity versus time were generated for foci showing rapid enhancement on subtracted contrast-enhanced images; semiquantitative, in which a biexponential heuristic model was used to generate color-coded maps depicting maximum slope and washout of contrast enhancement; and quantitative, in which a Tofts model was used to generate color-coded influx rate transfer constant (Ktrans) and efflux rate transfer constant (Kep) maps. Findings were stratified by whether suspicious foci showed evidence of washout with each method and compared with histopathologic results in each sextant. There was similar accuracy for the semiquantitative and quantitative models for both observers irrespective of requiring evidence of washout. For the more experienced observer, requiring washout resulted in lower sensitivity and higher specificity for the qualitative and semiquantitative models. Also for the more experienced observer, use of either a semiquantitative or quantitative model provided greater sensitivity compared with a qualitative model when requiring washout. There was no association between tumor detection and Gleason score for any DCE-MRI methodology for either reader. For the experienced reader, sensitivity for peripheral zone tumor was increased by use of either a semiquantitative or quantitative model compared with a qualitative model and decreased by requiring washout. We failed to identify a difference in performance between semiquantitative and quantitative models.

Struma ovarii recurrence with peritoneal strumosis: A case report

Background: Malignant transformation of thyroid tissue in struma ovarii and metastasis are uncommon. Benign thyroid tissue may spread to the peritoneal cavity in rare cases, and pathologic examination of the peritoneal implants shows multiple nodules of varying sizes of mature thyroid tissue similar to struma ovarii. This condition is termed “peritoneal strumosis”. It is very rare and therefore, both the criteria for diagnosis and its management are under discussion. The recommended treatment of metastatic struma ovarii should contain, in addition to local resection of the extraovarian tumor, total thyroidectomy in conjunction with radioiodine scanning and radioiodine ablation. Case report: A 38 year-old woman had presented with benign struma ovarii 12 years previously. She was referred to our department because of a right ovarian tumor. After confirming the diagnoses of metastatic recurrent benign struma ovarii, we performed debulking surgery with the aim of resecting all tumor masses. The uterus, left adnexa, and pelvic peritoneum were surgically extracted “en bloc”. No macroscopic tumor was left post-operatively. The first post operative 123 I scintography with15 MBq iodine-123 one month post-operatively showed a small but suspicious focus in the front left perivesical pelvic area. In the ventral visual presentation multiple discrete foci, located in right perivesical, supravesical and in the ventral upper abdomen, were seen. We then referred the patient for thyroidectomy and radioiodine ablation. The following periodic follow-ups of the patient did not show any signs of recurrence or progression of the disease. Conclusion: Patient with benign metastatic struma ovarii (also known as Highly differentiated follicular carcinoma of ovarian origin - HDFCO) may affectively be treated with local resection of the extraovarian tumor and subsequent thyroidectomy followed by radioactive iodine ablation.

Comparison of Patient Characteristics and Outcomes of Contralateral Prophylactic Mastectomy and Unilateral Total Mastectomy in Breast Cancer Patients

There has been an increasing trend toward contralateral prophylactic mastectomy (CPM) in the management of breast cancer (BCa). This study's objective was to compare clinicopathologic characteristics of BCa patients who elected CPM to those who elected unilateral total mastectomy (UTM) and to determine whether CPM improved survival. Comparison was performed on 355 patients with stage 0-III BCa matched by age and stage who underwent mastectomy from 1995 to 2008: 177 patients had CPM; 178 patients had UTM. Clinicopathological characteristics and survival outcomes were analyzed. Women who underwent preoperative MRI were twice as likely to have CPM (40.9 vs. 19.7%, P < 0.001). MRI identified additional suspicious foci in 45% CPM and 19% UTM. Patients with history of previous breast biopsies, family history, or BRCA mutation were more likely to choose CPM than UTM (40.1 vs. 24%, P = 0.001; 64.3 vs. 41.4%, P < 0.001; 20.3 vs. 6.5%, P = 0.04, respectively). CPM patients elected nipple preservation (26 vs. 5.2%, P < 0.001) and immediate reconstruction more often (92.2 vs. 73.5%, P < 0.001); UTM patients were more likely to have attempted breast conservation prior to mastectomy (52.8 vs. 39.5%, P = 0.01). CPM identified occult BCa in 11 patients (6.6%), and three UTM patients (1.7%) developed contralateral BCa. With median follow-up of 61 months, by univariable/multivariable analyses, CPM did not improve overall, disease-free, or distant metastases-free survival. Factors that may influence choice of CPM included preoperative MRI, history of prior breast biopsies, immediate reconstruction, nipple preservation, family history, and BRCA status. Those who chose CPM did not have improved survival.

Utility of immunohistochemistry markers in the interpretation of post-high-intensive focussed ultrasound prostate biopsy cores

To overcome the difficulties in the interpretation of postoperative tumor obtaining biopsy cores for patients who treated their prostate cancer with high-intensity focussed ultrasound (HIFU) therapy. The H&E slides of 58 patients with residual prostate cancer after HIFU treatment were systematically reviewed. Correlation between the pathologist's findings and immunohistochemical expression of MIB-1, alpha-Methyl-Co-Racemase and 34βE-12 staining was analyzed. Mean time from treatment to biopsy was 40.2 (8-208) weeks. The expert review of the H&E slides identified 40 patients with viable carcinoma in the post-HIFU biopsy cores. 18 patients were revised to necrosis-only-tumors. These biopsies were performed not later than 16 weeks after HIFU treatment (median 10.9 weeks, range 8-14). Both MIB-1 and AMACR staining displayed significant differential expression in viable carcinoma (p < 0.001) compared to necrosis tumors. Referring to viable carcinoma tissue, AMACR staining index was significantly rising, the longer treatment dated back from biopsy (p < 0.002). In this context, 34-β-E12 stained negative through all tumor areas and positive in the majority (85%) of the surrounding non-neoplastic epithelium. AMACR and MIB-1 reliably differentiate viable carcinoma from a process of ongoing irreversible necrosis in early post-HIFU prostate biopsy cores and therefore proposed-in addition with 34 beta-E12-as useful markers exposing suspicious tumor foci in difficult cases.

The application of Levulan®-based photodynamic therapy with imiquimod in the treatment of recurrent basal cell carcinoma

SummaryBackgroundCommon skin tumors like basal- and squamous-cell carcinoma present a serious problem in modern medicine. Exposure to ultraviolet solar radiation is the main cause of these lesions. Since application of Aldara® and PDT separately is well documented, we decided to use both methods together.The aim of our study was to evaluate the effectiveness of local photodynamic therapy supplemented with topical application of Aldara® in basal-cell carcinoma.Material/MethodsThirty-four patients ages 50 to 68 years were enrolled to the trial and underwent PDT treatment. Each case of BCC was histopathologically confirmed. Ten patients were subjected to local Levulan®-PDT and placebo (Eucerin as vehicle cream), and 24 patients were subjected to Levulan®-PDT and imiquimod. Photodynamic diagnosis (PDD) was used to detect and visualize suspicious foci (including cancer lesions).ResultsIn the group of patients who were treated using Levulan®-PDT and placebo, 6 patients (60%) were totally cured and 4 lesions (40%) significantly decreased in size. In the group of patients treated with Levulan®-PDT and imiquimod, 18 lesions totally disappeared (75%), 6 lesions significantly diminished, and in 1 patient small foci of previously excised BCC developed again in scar tissue 10 month after the first control examination.ConclusionsCure was achieved without any scarring and with very good cosmetic effects. Although this is the preliminary report, the presented modification of PDT seems to be reasonable and promising in treating basal-cell carcinoma.

UP-02.135 Atypical Small Acinar Proliferation in Extended Transrectal Prostate Biopsy: Meaning and Clinical Implications

Atypical small acinar proliferation (ASAP) presents itself as a suspicious foci but not diagnostic of malignancy. In classic prostate biopsy (6-8 cores) finding an ASAP was correlated with carcinoma in the rebiopsy in > 50% of the cases. It is not yet known if this association is equally strong in extended schemes with their higher rate of diagnosis at the first biopsy. Primary objective: to assess the rate of detection of carcinoma. Secondary objective: to determine the incidence of ASAP and establish the importance of our protocol of biopsies.

Magnetic Resonance Imaging for the Detection, Localisation, and Characterisation of Prostate Cancer: Recommendations from a European Consensus Meeting

BackgroundMultiparametric magnetic resonance imaging (mpMRI) may have a role in detecting clinically significant prostate cancer in men with raised serum prostate-specific antigen levels. Variations in technique and the interpretation of images have contributed to inconsistency in its reported performance characteristics. ObjectiveOur aim was to make recommendations on a standardised method for the conduct, interpretation, and reporting of prostate mpMRI for prostate cancer detection and localisation. Design, setting, and participantsA consensus meeting of 16 European prostate cancer experts was held that followed the UCLA-RAND Appropriateness Method and facilitated by an independent chair. MeasurementBefore the meeting, 520 items were scored for “appropriateness” by panel members, discussed face to face, and rescored. Results and limitationsAgreement was reached in 67% of 260 items related to imaging sequence parameters. T2-weighted, dynamic contrast-enhanced, and diffusion-weighted MRI were the key sequences incorporated into the minimum requirements. Consensus was also reached on 54% of 260 items related to image interpretation and reporting, including features of malignancy on individual sequences. A 5-point scale was agreed on for communicating the probability of malignancy, with a minimum of 16 prostatic regions of interest, to include a pictorial representation of suspicious foci. Limitations relate to consensus methodology. Dominant personalities are known to affect the opinions of the group and were countered by a neutral chairperson. ConclusionsConsensus was reached on a number of areas related to the conduct, interpretation, and reporting of mpMRI for the detection, localisation, and characterisation of prostate cancer. Before optimal dissemination of this technology, these outcomes will require formal validation in prospective trials.

Comparison of power Doppler ultrasound with gray scale transrectal ultrasound in predicting cancer positive prostate biopsy cores.

The aim of this study is to compare the effect of transrectal power Doppler ultrasound (PDUS) and gray scale transrectal ultrasound (TRUS) for the diagnosis of prostate cancer. Seventy-six patients evaluated with transrectal PDUS and TRUS underwent eight systematic TRUS guided core-needle biopsies, with additional cores from abnormal areas. Histologic diagnoses were classified as benign prostatic hyperplasia, chronic prostatitis, intraepithelial neoplasia and adenocarcinoma. TRUS and PDUS findings of the cases were recorded. PDUS sensitivity, specificity, positive predictive value (PPV) and negative predictive values were 81%, 81%, 54% and 94%, respectively. PDUS had a greater sensitivity and specificity than TRUS (43% and 60%, respectively) and identified cancer cases more accurately (Table 2). Hypervascular foci in PDUS signify suitable zones for biopsy. When combined with systematic TRUS guided biopsy, PDUS increases the cancer detection rate with additional biopsies from suspicious hypervascular foci. Transrectal PDUS guided biopsy should be combined with gray scale TRUS guided biopsy to increase accuracy in the diagnosis of prostate cancer.

Limitations of Conventional Contrast-enhanced MRI in Selecting Sentinel Node Biopsy Candidates among DCIS Patients

Purpose: A better predictive model for occult invasive disease in ductal carcinoma in situ (DCIS) patients is essential to guide the tailored use of sentinel node biopsies. We hypothesized that recent improvement of contrast-enhanced breast magnetic resonance imaging (MRI) could provide more accurate information on the presence of occult invasion in DCIS patients. Methods: From a prospectively maintained database, we identified 143 DCIS patients diagnosed with needle biopsies in whom MRI images were available. Results: Sixty-five patients (45.5%) were upstaged to invasive carcinoma after curative surgery. Ultrasonographic lesion size, mass-appearance on mammography, type of needle used, and the presence of suspicious microinvasive foci were associated with increased likelihood of upstaging. Among the features of MRI, only mass-appearance was significantly associated with the presence of invasive disease (p=0.002). However, up to 50% of masses in MRI cases had massappearance on mammography as well. Other morphologic and pharmacokinetic features of MRI, such as shape, margin, and patterns of enhancement and washout, did not have a significant association. Conclusion: Among various morphologic and pharmacokinetic parameters of contrast-enhanced MRI, only mass-appearance was associated with occult invasive disease. Our results show the limitations of current contrast-enhanced MRI in predicting invasive disease in patients with preoperative diagnoses of DCIS.

Detection of Cancer in Radical Prostatectomy Specimens With no Residual Carcinoma in the Initial Review of Slides

Radical prostatectomy (RP) specimens occasionally contain no carcinoma in the initial slides of an entirely submitted specimen, but no protocol has been established to assess for carcinoma in the remainder of the specimen. We evaluated 34 cases with no carcinoma in the initial slide review of the entirely submitted RP over a 2-year interval out of 2200 RPs. Our sequential protocol for cases with no initial tumor is (1) review the biopsy; (2) do immunostains on suspicious foci; (3) perform levels on blocks with high-grade prostatic intraepithelial neoplasia; (4) perform 3 levels on the posterior sextant and adjacent sextant region where cancer was identified on biopsy; and (5) flip the blocks in these regions and perform 3 additional levels. The mean age was 58.1 years (41 to 69 y) with a mean prostate-specific antigen level of 5.9 ng/mL (0.8 to 19 ng/mL). On review, all of the biopsies had carcinoma with a Gleason score (GS) of 3+3=6. The number of positive cores was 1 [n=29 (85%)], 2 (n=3), 3 (n=1), and 4 (n=1). Fifty-nine percent (20/34) of the biopsies had immunohistochemistry (IHC) for basal cells and/or alpha-methylacyl CoA racemase. RPs on average weighed 73.6 g (36 to 155 g). Of the 34 cases with no initial cancer, cancer was found in 26 (76%), and 8 (24%) had no residual carcinoma despite extensive leveling in all cases and IHC in 1 case. IHC was performed on 12 of the 34 RP cases. Of 26 RP cases with cancer, 22 had cancer on only 1 slide, and 4 had cancer on 2 slides. All of the cancers in the radical prostatectomies were GS 6, and the GS agreed with the corresponding biopsy in all cases. In 83% (20/24) of cases that specified laterality in the biopsy, RP carcinoma was ipsilateral to carcinoma in the biopsy. In 93% (14/15) of the cases that specified sextant site in the biopsy, the location of the carcinoma in the RP was in the same or the adjacent inferior-superior sextant site. Of the 29 cases that required leveling, in 7 cases cancer was found only after flipping the blocks and doing additional levels. Of the 8 cases with no cancer, all biopsies had only 1 positive core with 6/8 having <10% of the core involved. In about 1.5% of RP cases no tumor will be seen in the initially entirely submitted specimen. A methodical limited targeted approach to identifying cancer can identify cancer in 73% of the cases with no initial cancer, yet there will still be 0.4% of all RPs where cancer is not been identified. As cancer was seen in areas away from the biopsy site in some of our cases with minute tumor, leveling all the blocks may have identified cancer in some of the cases in which we found no tumor with our protocol.

Computer-assisted diagnosis of prostate cancer using DCE-MRI data: design, implementation and preliminary results

We present computer-assisted diagnosis (CAD) software designed to improve prostate cancer detection using perfusion MRI data. In addition to standard visualization features, this software allows for the 2D and multislice 2D contouring of suspicious areas based on a seeded region growing algorithm, and area labeling based on zonal anatomy. Tumor volume assessment and the semiquantitative analysis of DCE-MRI sequences can both be performed. We retrospectively analyzed DCE-MRI examinations of 100 patients and found 121 lesions showing a suspiciously high intensity with early enhancement in 84 of them. Seventy-one patients turned out to be malignant, whereas 50 were benign. Based on an analysis of the median wash-in and wash-out values of these foci, we designed a standardized 5-level cancer suspicion score (ranging from "probably benign" to "highly suspicious"). This comprehensive score provides a scaled likelihood of malignancy in the region of interest taking account of its location in relation to prostate zonal anatomy. We compared its accuracy with that of visual assessments of time-intensity curves performed by specialist and non-specialist radiologists. Parameters of the scoring algorithm were designed to provide the greatest possible sensitivity in our sample population. A re-substitution evaluation provided an Se/Sp of 100/45% for peripheral zone cancer, and 100/40% for transition zone cancer characterization. When identifying malignant areas using time-intensity curves data, this simple algorithm performed significantly better (AUC = 0.77) than a non-specialist (AUC = 0.57, P < 0.0001) radiologist, and better than a trained (AUC = 0.70) radiologist, although this difference was not significant. Our new prostate MRI CAD software provides a standardized cancer suspicion score for suspicious foci detected in DCE-MRI T1-w images. Our results suggest that it may improve radiologists' performances in prostate cancer identification, especially when they are not specialized in prostate imaging.