Imaging of neuroendocrine neoplasms of the male GU tract

Male genitourinary neuroendocrine neoplasms (GU-NENs) are rare, without any definite imaging characteristics. The WHO classified neuroendocrine neoplasms in the 2016 classification of the tumors of the urinary tract and genital organs along with other GU tumors; however, no pathologic grading system is available as published for gastroenteropancreatic neuroendocrine neoplasms. Often a multimodality approach using cross-sectional imaging techniques, such as molecular imaging and histopathology are implemented to arrive at the diagnosis. This article provides a review of the pathology and imaging features of the male GU-NENs.

Magnetic resonance imaging of bladder pheochromocytomas: a review

Bladder pheochromocytomas (PCCs) are rare tumors that account for 0.06% of all bladder tumors and makeup 1% of all PCCs. Most PCCs are functional, and they secrete catecholamines that lead to clinical symptoms such as paroxysmal hypertension, headaches, palpitations, and sweating. However, some are nonfunctional and asymptomatic and are hence difficult to diagnose. Cystoscopy and biopsy should not be performed when bladder PCCs are suspected. They may provoke a hypertensive crisis if preventative antiadrenergic blockers are not administered prior to the procedure. The diagnostic workup begins with obtaining blood or urine catecholamine and catecholamine metabolite values to make a presumptive diagnosis of bladder PCC. Computed tomography (C.T.) and magnetic resonance imaging (MRI) are then used to localize and stage the tumor for surgical resection. MRI, due to its superior soft tissue resolution and the ability to use multiparametric MRI (mpMRI) to differentiate between layers of the bladder wall and from other bladder masses, is the optimal imaging modality to detect extra-adrenal bladder PCCs and determine locoregional staging. Once antiadrenergic medications are given, the tumor is resected, and the diagnosis is confirmed histologically. However, the differential diagnosis of bladder PCC often gets overlooked, leading to surgical resection in the absence of antiadrenergic medications, increasing the chances of a fatal hypertensive crisis. This makes MRI an essential diagnostic tool for staging bladder PCCs before surgery. This review discusses the indications for MRI in bladder PCCs and describes findings from these tumors on various MRI sequences and when to use them. We also discuss how MRI can differentiate bladder PCCs from other bladder neoplasms.

Recent Imaging Updates and Advances in Gynecologic Malignancies

Gynecologic malignancies are among the most common cancers in women worldwide and account for significant morbidity and mortality. Management and consequently overall patient survival is reliant upon early detection, accurate staging and early detection of any recurrence. Ultrasound, Computed Tomography (CT), Magnetic resonance imaging (MRI) and Positron Emission Tomography-Computed Tomography (PET-CT) play an essential role in the detection, characterization, staging and restaging of the most common gynecologic malignancies, namely the cervical, endometrial and ovarian malignancies. Recent advances in imaging including functional MRI, hybrid imaging with Positron Emission Tomography (PET/MRI) contribute even more to lesion specification and overall role of imaging in gynecologic malignancies. Radiomics is a neoteric approach which aspires to enhance decision support by extracting quantitative information from radiological imaging.

Nab-Paclitaxel, Capecitabine, and Radiation Therapy After Induction Chemotherapy in Treating Patients With Locally Advanced and Borderline Resectable Pancreatic Cancer: Phase 1 Trial and Imaging-based Biomarker Validation

PURPOSE

Effective consolidative chemoradiation (CRT) regimens are lacking. In this phase 1 trial, we evaluated the safety and efficacy of nab-paclitaxel, capecitabine, and radiation therapy after induction chemotherapy in patients with locally advanced and borderline-resectable pancreatic cancer (LAPC and BRPC). Also, we evaluated a computed tomography (CT)-based biomarker of response.

METHODS AND MATERIALS

Eligible patients had pathologically confirmed pancreatic ductal adenocarcinoma, underwent computed tomography-imaging, received a diagnosis of LAPC or BRPC, and received induction chemotherapy. Standard 3 + 3 study design was used, with 3 escalating nab-paclitaxel dose levels (50, 75, and 100 mg/m²) with concurrent capecitabine and RT in cohort sizes of 3 starting at the lowest dose. Dose limiting toxicity was defined as grade 3 or higher toxicity. Patients were restaged 4 to 6 weeks post-CRT completion, and surgical resection was offered to those with stable/responsive disease. We scored the tumor interface response (IR) postchemotherapy and post-CRT into type I (remained/became more defined) and type II (became less defined). Overall survival (OS) and progression-free survival (PFS) from time of CRT were estimated using Kaplan-Meier method. P ≤ .05 was considered significant.

RESULTS

Twenty-three patients started and finished on protocol (LAPC = 14, BRPC = 9). No grade 3 and 4 toxicities were reported in level 1 (n = 3) or level 2 (n = 3) initial groups. Two patients in the initial level 3 group developed dose limiting toxicity, establishing level 2 dose as the maximal tolerated dose. Level 2 group was expanded for additional 15 patients (for a total of 23 on trial), 5 of whom developed grade 3 toxicities. Seven patients underwent surgical resection. Median OS and PFS were 21.2 and 8.1 months, respectively. Type I IR was associated with better OS (P = .004) and PFS (P = .03) compared with type II IR.

CONCLUSIONS

We established the maximum tolerated dose for nab-paclitaxel in a consolidative CRT regimen for pancreatic ductal adenocarcinoma. Preliminary efficacy results warrant phase 2 trial evaluation. IR may be used for personalized treatment.

Utility of the Diffusion Weighted Sequence in Gynecological Imaging: Review Article

Simple Summary

Diffusion weighted imaging (DWI) is a magnetic resonance imaging sequence with diverse clinical applications in malignant and nonmalignant gynecological conditions. It provides vital supplemental information in the diagnosis and management of various gynecological conditions. Radiologists should be aware of fundamental concepts, clinical applications and pitfalls of DWI. Additionally we briefly discuss potential scope of newer advanced techniques based on DWI including diffusion tensor imaging and diffusion-weighted whole-body imaging with background signal suppression.

Abstract

Functional imaging with diffusion-weighted imaging (DWI) is a complementary tool to conventional diagnostic magnetic resonance imaging sequences. It is being increasingly investigated to predict tumor response and assess tumor recurrence. We elucidate the specific technical modifications of DWI preferred for gynecological imaging, including the different b-values and planes for image acquisition. Additionally, we discuss the problems and potential pitfalls encountered during DWI interpretation and ways to overcome them. DWI has a wide range of clinical applications in malignant and non-malignant gynecological conditions. It provides supplemental information helpful in diagnosing and managing tubo-ovarian abscess, uterine fibroids, endometriosis, adnexal torsion, and dermoid. Similarly, DWI has diverse applications in gynecological oncology in diagnosis, staging, detection of recurrent disease, and tumor response assessment. Quantitative evaluation with apparent diffusion coefficient (ADC) measurement is being increasingly evaluated for correlation with various tumor parameters in managing gynecological malignancies aiding in preoperative treatment planning. Newer advanced DWI techniques of diffusion tensor imaging (DTI) and whole body DWI with background suppression (DWIBS) and their potential uses in pelvic nerve mapping, preoperative planning, and fertility-preserving surgeries are briefly discussed.

Introducing and Building a Dual-Energy CT Business

In recent years, there has been increased utilization of Dual-energy CT (DECT) in diagnostic imaging, mainly due to a reduction of effective radiation dose and lower intravenous contrast dose requirement in DECT imaging compared to conventional CT. A comprehensive imaging protocol and teamwork involving technologists and radiologists are needed to successfully implement DECT in clinical practice. At the same time, insight into the direct and indirect expenditures incurred is critical for rendering a cost-effective service to the patient and institution. This paper focuses on introducing the foundations of DECT to the readers and discusses the impediments encountered during the implementation of DECT in clinical practice. Potential solutions to these challenges are also proposed.

Dual-Energy Imaging of the Chest

Dual-energy computed tomography (DECT) is a contemporary development by which the tissue can be characterized beyond conventional computed tomography. It improves tissue differentiation by exploiting the X-ray absorptive property of the tissues. Although still in its early stages, DECT utilization in pulmonary and cardiovascular pathologies is emerging. It includes applications such as pulmonary embolism, pulmonary hypertension, myocardial perfusion, and coronary artery assessment. This article discusses DECT principles and their current and emerging applications in thoracic imaging.

Virtual Non-contrast Imaging in The Abdomen and The Pelvis: An Overview

Virtual non-contrast (VNC) imaging is a post-processing technique generated from contrast-enhanced scans using dual-energy computed tomography (DECT). It is generated by removing iodine from imaging acquired at multiple energies. Myriad clinical studies have shown its ability to diagnose the various abdominal and pelvic pathologies discussed in the article. VNC is also a problem-solving tool for characterizing incidentally detected lesions ("incidentalomas"), often decreasing the need for additional follow-up imaging. It also obviates the multiphase image acquisitions to evaluate hematuria, hepatic steatosis, aortic endoleaks, and gastrointestinal bleeding by generating image datasets from different tissue attenuation values. The scope of this article is to provide an overview of various applications of VNC imaging obtained by DECT in the abdomen and pelvis.

Clinical Outcomes of Patients with Recurrent Microsatellite-Stable Endometrial Cancer in Early-Phase Immunotherapy Clinical Trials

Simple Summary

There is a crucial need to improve treatment regimens in patients with recurrent endometrial cancer. Although immunotherapy treatments have shown impressive benefit in microsatellite instability-high endometrial cancer, they have been less predictable in the majority of endometrial cancers, which are microsatellite stable. Our aim was to characterize clinical outcomes in patients with recurrent microsatellite stable endometrial cancer treated in early-phase immunotherapy clinical trials in order unravel treatment regimens that would improve response and survival. Our findings suggest that utilizing immunotherapy in combination with other non-immunotherapy agents resulted in greater duration of disease control and improved survival outcomes compared to immunotherapy only (monotherapy) or in combination with other immunotherapy agents. Future studies are needed to validate these findings.

Abstract

Recurrent microsatellite stable (MSS) endometrial cancer has poor response to conventional therapy and limited efficacy with immune checkpoint monotherapy. We conducted a retrospective study of recurrent MSS endometrial cancer patients enrolled in immunotherapy-based clinical trials at MD Anderson Cancer Center between 1 January 2010 and 31 December 2019. Patients were evaluated for radiologic response using RECIST 1.1 criteria, progression-free survival (PFS), and overall survival (OS). Thirty-five patients were treated with immune checkpoint inhibitors: 8 with monotherapy, 17 with immunotherapy (IO) in combination with another IO-only, and 10 with IO in combination with non-IO therapy. Among those treated with combination IO plus non-IO therapy, one had a partial response but 50% had clinical benefit. Patients who received combination IO plus non-IO therapy had improved PFS compared to those who received monotherapy (HR 0.56, 95% CI 0.33–0.97; p = 0.037) or combination IO-only therapy (HR 0.36, 95% CI 0.15–0.90; p = 0.028) and had improved OS when compared to monotherapy after adjusting for prior lines of therapy (HR 0.50, 95% CI 0.27–0.95; p = 0.036). The potential beneficial clinical outcomes of combination IO plus non-IO therapy in MSS endometrial cancer should be validated in a larger study.

PAs and NPs improve patient care and productivity in a radiology consult practice

OBJECTIVE

To evaluate the effects on efficiency and patient care of the addition of physician assistants (PAs) and NPs to the abdominal radiology consult service.

METHODS

We obtained radiologist productivity and patient care metrics for 3 months before and 3 months after the integration of PAs and NPs into our consult service.

RESULTS

Integrating PAs and NPs into the workflow led to a significant increase in mean RVUs/shift (15.2 ± 0.9 versus 6.2 ± 1.8; P = .02), number of studies read per shift (10.1 ± 0.5 versus 4.4 ± 1.5; P = .003), revenue per shift hour ($756.20 ± $55.40 versus $335.40 ± $132.60; P = .007), protocol prescription to patient appointment lead time (39.3 ± 6.7 versus 16.3 ± 2.9 days; P = .005), and significant decreases in mean CT (19.3% ± 0.6 versus 3.3% ± 0.6; P = .001) and MRI (11.7% ± 0.6 versus 8.3% ± 0.12; P = .011) same-day protocol changes as patient appointments.

CONCLUSIONS

PAs and NPs can be effectively integrated into abdominal radiology consult service, increasing the productivity of radiologists, and enhancing clinical care.

Advances and effectiveness of the immunotherapy after liver transplantation

Transplant recipients usually have increased chances of graft rejection and graft vs host disease, requiring chronic immunosuppressive therapy. Nonetheless, long-term immunosuppression risks malignancies such as skin cancer, lymphoma, and Kaposi sarcoma. However, there are very few studies that included solid organ transplant recipients while studying the efficacy of immunotherapy. “Immunotherapy after liver transplantation: Where are we now?” is a study, where the authors described the mechanism of action and outcomes of immune checkpoint inhibitors specific to liver transplant recipients. The authors reported the graft rejection rates and the factors contributing to the rejection in the liver transplant recipients.

Phase II Study of Ramucirumab in Advanced Biliary Tract Cancer Previously Treated By Gemcitabine-Based Chemotherapy

PURPOSE

VEGF receptor-2 (VEGFR-2)-mediated angiogenesis contributes to pathogenesis of biliary tract cancers (BTC). We investigated ramucirumab, a mAb targeting VEGFR-2 for treatment of advanced, chemorefractory BTC.

PATIENTS AND METHODS

This is a phase II, single-arm trial for advanced, unresectable, pre-treated patients with BTC with ECOG 0/1, adequate liver, renal, and marrow functions. Ramucirumab was administered at 8 mg/kg, 2 weekly with restaging performed 8 weekly. Primary endpoint was progression-free survival (PFS). Secondary endpoints were overall response rate (ORR), disease control rate (DCR), overall survival (OS), and toxicity. Exploratory endpoints included correlation of tumor mutational status with PFS and OS.

RESULTS

61 patients were enrolled: the median age was 58.5 years; 59 with stage IV disease; 62%, intrahepatic cholangiocarcinoma; 22%, gallbladder cancer; and 16%, extrahepatic cholangiocarcinoma. All received prior chemotherapy: 52% had 1 prior, and rest ≥2 prior lines. Median treatment duration was 10.1 weeks (range, 2.1-86). Median PFS was 3.2 months [95% confidence interval (CI), 2.1-4.8]; median OS, 9.5 months (95% CI, 5.8-13.6). One (1.7%) patient achieved partial response; 26 (43.3%), stable disease; and 25 (41.7%), disease progression; DCR, 45%. Median 6-month PFS and OS rates were 32% (95% CI, 0.22-0.46) and 58% (95% CI, 0.47-0.72). The majority of toxicities were grade 1 or 2; grade 3 proteinuria (1, 2%), hypertension (13, 22%), and pulmonary embolism (1, 2%), and grade 4 gastrointestinal bleeding (1, 2%) occurred.

CONCLUSIONS

Ramucirumab was well tolerated and resulted in PFS similar to that achieved with other chemotherapy regimens used historically for chemorefractory BTC.

Phase Ib study of selinexor and eribulin combination in advanced solid tumors and triple-negative breast cancer

3108

Background: Selinexor (KPT-330) is potent inhibitor of Exportin-1. In vitro, Selinexor was found to be synergistic with eribulin in triple negative breast cancer (TNBC) cell lines and enhanced antitumor activity of eribulin in TNBC patient-derived xenografts (PMID 28810913). Methods: We conducted a phase Ib trial in combination of selinexor and eribulin using 3 + 3 design in dose escalation for patients with advanced solid tumors and in TNBC in dose expansion cohort. Eribulin could be discontinued after combination for 6 cycles at physician discretion. Primary objectives: Safety, Recommended Phase 2 Dose (RP2D). Secondary Objectives: Objective Response Rate (ORR), Duration of Response (DOR), Disease Control Rate (DCR), Overall Survival (OS) and Progression Free Survival (PFS). Results: 31 patients, TNBC (n = 19), sarcoma (n = 8), others (n = 4) enrolled in dose escalation (n = 10) and dose expansion phases (n = 21). Median prior therapies:4 (1–6). Study initiated selinexor at 60mg twice weekly and eribulin 1.4mg/m2 on Day1, Day8 every 3 weeks which led to 1 Dose Limiting Toxicity (DLT) and hence, selinexor 80mg once weekly and eribulin 1mg/m2 was elected as RP2D due to efficacy and tolerability. As of 01/15/2022, of 29 patients (94%) who have discontinued treatment, 24 (77%) were due to progressive disease, 3 (10%) withdrew consent and 2 (6%) due to toxicities (G1 pneumonitis; G3 neutropenia) while 2 (6%) remain on trial. All 31 patients had at least one treatment emergent adverse event (TEAE) while most prevalent TEAEs (all grades) were leukopenia (77%), nausea (71%), anemia and neutropenia (68%) and fatigue (48%). The most common G3/4 TEAE were leukopenia (26%) and neutropenia (29%). 2 DLTs occurred; 1 in first dose level (DL); 1 in second DL dosed at selinexor 80 mg once weekly due to G3 neutropenia. ORR for all was 10% while DCR (SD+PR+CR) > 6 months seen in 3 (15%) TNBC and 2 (20%) sarcoma patients. The median OS and PFS for all were 12.3 (7.3, 27.3) months and 2.3 (1.6, 4.1) months. In dose escalation cohort, ORR was 10% where one patient (3%) with vaginal SCC had confirmed PR (-44%) for 2.1 months. Five patients (62.5%) with sarcoma had stable disease (SD). One patient with high grade sarcoma has SD for 68 months and remains on selinexor after 4 months of eribulin and selinexor. In TNBC dose expansion (n = 19), ORR was 10.5% with 2 confirmed PRs and median duration of response (DOR) of 10.8 months. One patient who has remained on treatment for 18 months, and after receiving 8 months of eribulin and selinexor, remains on selinexor with 100% target regression and an indeterminate brain lesion. Conclusions: Selinexor with eribulin is safe with manageable toxicity profile and modest overall clinical efficacy. Durable responses and disease control were observed with metastatic TNBC. Further study is needed to examine the determinants of response to this combination. Clinical trial information: NCT02419495.

Metabolic complete responses (mCR) in patients with metastatic uveal melanoma (mUM) treated with image-guided injection (IGI) of PV-10

9543

Background: Traditional CT imaging can underestimate the degree of anti-cancer treatment effect due to reliance on morphological changes of visualized tumors. In contrast, PET imaging offers information on metabolic activity using a positron emitting radiolabeled agent (e.g. FDG) but is less sensitive to changes in tumor size. FDG-PET images acquired, co-registered, and superimposed on CT images (PET-CT) allow spatial detection of anti-cancer activity. Moreoever, FDG-PET-CT can provide information regarding anti-tumor immune responses in patients receiving immunotherapy. Rose bengal (PV-10) is a small molecule autolytic immunotherapy in development for metastatic disease. When administered by intralesional injection, PV-10 can produce immunogenic cell death and a T-cell mediated immune response against treatment-refractory and immunologically-cold tumors. Herein, we report the FDG-PET-CT imaging responses of 7 metastatic uveal melanoma (mUM) patients who received percutaneous image-guided injection (IGI) of PV-10 into hepatic tumors. Methods: The Phase 1 study is evaluating safety, tolerability, and efficacy of intralesional PV-10 in hepatic tumors. PV-10 is administered percutaneously via IGI into designated tumors ≤4.9 cm in diameter. Response is assessed at Day 28, then every 3 months, using CT/MRI or PET-CT. Patients with multiple tumors may receive further IGI of PV-10 after Day 28. Results: To date, 25 mUM patients with liver metastases have been treated; 16 patients received standard of care immune checkpoint inhibitor (ICI) during or post PV-10 treatment. Seven subjects had FDG-PET-CT imaging during the study (baseline 1, follow-up 6). Two follow-up FDG-PET-CTs were performed 1 and 3 years after PV-10 injection with intervening ICI, and another was 1.5 years after PV-10, without any follow-on treatment. Four patients experienced mCR in all metastatic sites, including extrahepatic metastasis. Conclusions: FDG-PET-CT shows that PV-10 is capable of inducing mCR in injected (adscopal) and non-injected (abscopal) lesions. This pattern of response is suggestive of immunogenic cell death in mUM patients with liver metastases. Clinical trial information: NCT00986661.

Vulvar Cancer: 2021 Revised FIGO Staging System and the Role of Imaging

Vulvar cancer is a rare gynecological malignancy. It constitutes 5-8% of all gynecologic neoplasms, and squamous cell carcinoma is the most common variant. This article aims to review the etiopathogenesis revised 2021 International Federation of Gynecology and Obstetrics (FIGO) classification and emphasize imaging in the staging of vulvar cancer. The staging has been regulated by FIGO since 1969 and is subjected to multiple revisions. Previous 2009 FIGO classification is limited by the prognostic capability, which prompted the 2021 revisions and issue of a new FIGO classification. Although vulvar cancer can be visualized clinically, imaging plays a crucial role in the staging of the tumor, assessing the tumor extent, and planning the management. In addition, sentinel lymph node biopsy facilitates the histopathological staging of the draining lymph node, thus enabling early detection of tumor metastases and better survival rates.

Assessment of Clinical Response Following Atezolizumab and Bevacizumab Treatment in Patients With Neuroendocrine Tumors: A Nonrandomized Clinical Trial

Importance

Therapies for patients with advanced well-differentiated neuroendocrine tumors (NETs) have expanded but remain inadequate, with patients dying of disease despite recent advances in NET therapy. While patients with other cancers have seen long-term disease control and tumor regression with the application of immunotherapies, initial prospective studies of single-agent programmed cell death 1 inhibitors in NET have been disappointing.

Objective

To evaluate the response rate following treatment with the combination of the vascular endothelial growth factor inhibitor bevacizumab with the programmed cell death 1 ligand 1 inhibitor atezolizumab in patients with advanced NETs.

Design, Setting, and Participants

This single-arm, open-label nonrandomized clinical study in patients with rare cancers included 40 patients with advanced, progressive grade 1 to 2 NETs (20 with pancreatic NETs [pNETs] and 20 with extrapancreatic NETs [epNETs]) treated at a tertiary care referral cancer center between March 31, 2017, and February 19, 2019. Data were analyzed from June to September 2021.

Interventions

Patients received intravenous bevacizumab and atezolizumab at standard doses every 3 weeks until progression, death, or withdrawal.

Main Outcomes and Measures

The primary end point was objective radiographic response using Response Evaluation Criteria in Solid Tumors, version 1.1, with progression-free survival (PFS) as a key secondary end point.

Results

Following treatment of the 40 study patients with bevacizumab and atezolizumab, objective response was observed in 4 patients with pNETs (20%; 95% CI, 5.7%-43.7%) and 3 patients with epNETs (15%; 95% CI, 3.2%-37.9%). The PFS was 14.9 (95% CI, 4.4-32.0) months and 14.2 (95% CI, 10.2-19.6) months in these cohorts, respectively.

Conclusions and Relevance

In this nonrandomized clinical trial, findings suggest that clinical responses in patients with NET may follow treatment with the combination of bevacizumab and atezolizumab, with a PFS consistent with effective therapies.

Trial Registration

ClinicalTrials.gov Identifier: NCT03074513.

Comments on "Review of the role of diagnostic modalities and imaging findings in the COVID-19 pandemic"

The present letter to the editor corresponds to the article entitled “Comprehensive literature review on the radiographic findings, imaging modalities, and the role of radiology in the coronavirus disease 2019 (COVID-19) pandemic” by Pal et al, published in World J Radiol. 2021; 13(9): 258-282. With zero to unknown prevalence, COVID-19 has created a heterogeneous and unforeseen situation across the world. Healthcare providers encountered new challenges in image interpretation, characterization, and prognostication of the disease. Pal et al delineated the radiological findings, which would guide the radiologists to identify the early signs of severe infection.

Defining Diagnostic Criteria for Prostatic Ductal Adenocarcinoma at Multiparametric MRI

Background Prostatic ductal adenocarcinoma (DAC) is an aggressive histologic variant of prostate cancer that often warrants multimodal therapy and poses a significant diagnostic challenge clinically and at imaging. Purpose To develop multiparametric MRI criteria to define DAC and to assess their diagnostic performance in differentiating DAC from prostatic acinar adenocarcinoma (PAC). Materials and Methods Men with histologically proven DAC who had multiparametric MRI before radical prostatectomy were retrospectively identified from January 2011 through November 2018. MRI features were predefined using a subset of nine DACs and then compared for men with peripheral-zone DACs 1 cm or greater in size and men with matched biopsy-confirmed International Society of Urological Pathology grade group 4-5 PAC, by four independent radiologists blinded to the pathologic diagnosis. Diagnostic performance was determined by consensus read. Patient and tumor characteristics were compared by using the Fisher test, t-tests, and Mann-Whitney U test. Agreement (Cohen κ) and sensitivity analyses were also performed. Results There were 59 men with DAC (median age, 63 years [interquartile range, 56, 67 years]) and 59 men with PAC (median age, 64 years [interquartile range, 59, 69 years]). Predefined MRI features, including intermediate T2 signal, well-defined margin, lobulation, and hypointense rim, were detected in a higher proportion of DACs than PACs (76% [45 of 59] vs 5% [three of 59]; P < .001). On consensus reading, the presence of three or more features demonstrated 76% sensitivity, 94% specificity, 94% positive predictive value [PPV], and 80% negative predictive value [NPV] for all DACs and 100% sensitivity, 95% specificity, 81% PPV, and 100% NPV for pure DACs. The DACs and PACs showed no difference in contrast enhancement (100% vs 100%; P >.99, median T2 signal intensity (254 vs 230; P = .99), or apparent diffusion coefficient (median, 677 10^-6 mm²/sec vs 685 10^-6 mm²/sec; P = .73). Conclusion The presence of intermediate T2 signal, well-defined margin, lobulation, and/or hypointense rim, together with restricted diffusion and contrast enhancement at multiparametric MRI of the prostate, suggests prostatic ductal adenocarcinoma rather than prostatic acinar adenocarcinoma. © RSNA, 2022 Online supplemental material is available for this article.

PIONEER-Panc: a platform trial for phase II randomized investigations of new and emerging therapies for localized pancreatic cancer

Background

Personalized and effective treatments for pancreatic ductal adenocarcinoma (PDAC) continue to remain elusive. Novel clinical trial designs that enable continual and rapid evaluation of novel therapeutics are needed. Here, we describe a platform clinical trial to address this unmet need.

Methods

This is a phase II study using a Bayesian platform design to evaluate multiple experimental arms against a control arm in patients with PDAC. We first separate patients into three clinical stage groups of localized PDAC (resectable, borderline resectable, and locally advanced disease), and further divide each stage group based on treatment history (treatment naïve or previously treated). The clinical stage and treatment history therefore define 6 different cohorts, and each cohort has one control arm but may have one or more experimental arms running simultaneously. Within each cohort, adaptive randomization rules are applied and patients will be randomized to either an experimental arm or the control arm accordingly. The experimental arm(s) of each cohort are only compared to the applicable cohort specific control arm. Experimental arms may be added independently to one or more cohorts during the study. Multiple correlative studies for tissue, blood, and imaging are also incorporated.

Discussion

To date, PDAC has been treated as a single disease, despite knowledge that there is substantial heterogeneity in disease presentation and biology. It is recognized that the current approach of single arm phase II trials and traditional phase III randomized studies are not well-suited for more personalized treatment strategies in PDAC. The PIONEER Panc platform clinical trial is designed to overcome these challenges and help advance our treatment strategies for this deadly disease.

Trial registration

This study is approved by the Institutional Review Board (IRB) of MD Anderson Cancer Center, IRB-approved protocol 2020-0075. The PIONEER trial is registered at the US National Institutes of Health (ClinicalTrials.gov) NCT04481204.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09095-7.

Metabolic Imaging Using Hyperpolarization for Assessment of Premalignancy

There is an unmet need for noninvasive surrogate markers that can help identify premalignant lesions across different tumor types. Here we describe the methodology and technical details of protocols employed for in vivo 13C pyruvate metabolic imaging experiments. The goal of the method described is to identify and understand metabolic changes, to enable detection of pancreatic premalignant lesions, as a proof of concept of the high sensitivity of this imaging modality.