Performance of T2 Maps in the Detection of Prostate Cancer

Longitudinal analysis of T2 relaxation time variations following radiotherapy for prostate cancer

Aim of this paper is to evaluate short and long-term changes in T 2 relaxation times after radiotherapy in patients with low and intermediate risk localized prostate cancer. A total of 24 patients were selected for this retrospective study. Each participant underwent 1.5T magnetic resonance imaging on seven separate occasions: initially after the implantation of gold fiducials, the required step for Cyberknife therapy guidance, followed by MRI scans two weeks post-therapy and monthly thereafter. As part of each MRI scan, the prostate region was manually delineated, and the T 2 relaxation times were calculated for quantitative analysis. The T 2 relaxation times between individual follow-ups were analyzed using Repeated Measures Analysis of Variance that revealed a significant difference across all measurements (F (6, 120) = 0.611, p << 0.001). A Bonferroni post hoc test revealed significant differences in median T 2 values between the baseline and subsequent measurements, particularly between pre-therapy (M 0 ) and two weeks post-therapy (M 1 ), as well as during the monthly interval checks (M 2 - M 6 ). Some cases showed a delayed decrease in relaxation times, indicating the prolonged effects of therapy. The changes in T 2 values during the course of radiotherapy can help in monitoring radiotherapy response in unconfirmed patients, quantifying the scarring process, and recognizing the therapy failure.

Prostate Cancers Invisible on Multiparametric MRI: Pathologic Features in Correlation with Whole-Mount Prostatectomy

We investigated why some prostate cancers (PCas) are not identified on multiparametric MRI (mpMRI) by using ground truth reference from whole-mount prostatectomy specimens. A total of 61 patients with biopsy-confirmed PCa underwent 3T mpMRI followed by prostatectomy. Lesions visible on MRI prospectively or retrospectively identified after correlating with histology were considered "identified cancers" (ICs). Lesions that could not be identified on mpMRI were considered "unidentified cancers" (UCs). Pathologists marked the Gleason score, stage, size, and density of the cancer glands and performed quantitative histology to calculate the tissue composition. Out of 115 cancers, 19 were unidentified on MRI. The UCs were significantly smaller and had lower Gleason scores and clinical stage lesions compared with the ICs. The UCs had significantly (p < 0.05) higher ADC (1.34 ± 0.38 vs. 1.02 ± 0.30 μm2/ms) and T2 (117.0 ± 31.1 vs. 97.1 ± 25.1 ms) compared with the ICs. The density of the cancer glands was significantly (p = 0.04) lower in the UCs. The percentage of the Gleason 4 component in Gleason 3 + 4 lesions was nominally (p = 0.15) higher in the ICs (20 ± 12%) compared with the UCs (15 ± 8%). The UCs had a significantly lower epithelium (32.9 ± 21.5 vs. 47.6 ± 13.1%, p = 0.034) and higher lumen volume (20.4 ± 10.0 vs. 13.3 ± 4.1%, p = 0.021) compared with the ICs. Independent from size and Gleason score, the tissue composition differences, specifically, the higher lumen and lower epithelium in UCs, can explain why some of the prostate cancers cannot be identified on mpMRI.

Retrospective T2 quantification from conventional weighted MRI of the prostate based on deep learning

Purpose

To develop a deep learning-based method to retrospectively quantify T2 from conventional T1- and T2-weighted images.

Methods

Twenty-five subjects were imaged using a multi-echo spin-echo sequence to estimate reference prostate T2 maps. Conventional T1- and T2-weighted images were acquired as the input images. A U-Net based neural network was developed to directly estimate T2 maps from the weighted images using a four-fold cross-validation training strategy. The structural similarity index (SSIM), peak signal-to-noise ratio (PSNR), mean percentage error (MPE), and Pearson correlation coefficient were calculated to evaluate the quality of network-estimated T2 maps. To explore the potential of this approach in clinical practice, a retrospective T2 quantification was performed on a high-risk prostate cancer cohort (Group 1) and a low-risk active surveillance cohort (Group 2). Tumor and non-tumor T2 values were evaluated by an experienced radiologist based on region of interest (ROI) analysis.

Results

The T2 maps generated by the trained network were consistent with the corresponding reference. Prostate tissue structures and contrast were well preserved, with a PSNR of 26.41 ± 1.17 dB, an SSIM of 0.85 ± 0.02, and a Pearson correlation coefficient of 0.86. Quantitative ROI analyses performed on 38 prostate cancer patients revealed estimated T2 values of 80.4 ± 14.4 ms and 106.8 ± 16.3 ms for tumor and non-tumor regions, respectively. ROI measurements showed a significant difference between tumor and non-tumor regions of the estimated T2 maps (P < 0.001). In the two-timepoints active surveillance cohort, patients defined as progressors exhibited lower estimated T2 values of the tumor ROIs at the second time point compared to the first time point. Additionally, the T2 difference between two time points for progressors was significantly greater than that for non-progressors (P = 0.010).

Conclusion

A deep learning method was developed to estimate prostate T2 maps retrospectively from clinically acquired T1- and T2-weighted images, which has the potential to improve prostate cancer diagnosis and characterization without requiring extra scans.

Magnetic Resonance Fingerprinting: A Review of Clinical Applications

ABSTRACT

Magnetic resonance fingerprinting (MRF) is an approach to quantitative magnetic resonance imaging that allows for efficient simultaneous measurements of multiple tissue properties, which are then used to create accurate and reproducible quantitative maps of these properties. As the technique has gained popularity, the extent of preclinical and clinical applications has vastly increased. The goal of this review is to provide an overview of currently investigated preclinical and clinical applications of MRF, as well as future directions. Topics covered include MRF in neuroimaging, neurovascular, prostate, liver, kidney, breast, abdominal quantitative imaging, cardiac, and musculoskeletal applications.

Advances in PET and MRI imaging of tumor hypoxia

Tumor hypoxia is a complex and evolving phenomenon both in time and space. Molecular imaging allows to approach these variations, but the tracers used have their own limitations. PET imaging has the disadvantage of low resolution and must take into account molecular biodistribution, but has the advantage of high targeting accuracy. The relationship between the signal in MRI imaging and oxygen is complex but hopefully it would lead to the detection of truly oxygen-depleted tissue. Different ways of imaging hypoxia are discussed in this review, with nuclear medicine tracers such as [¹⁸F]-FMISO, [¹⁸F]-FAZA, or [⁶⁴Cu]-ATSM but also with MRI techniques such as perfusion imaging, diffusion MRI or oxygen-enhanced MRI. Hypoxia is a pejorative factor regarding aggressiveness, tumor dissemination and resistance to treatments. Therefore, having accurate tools is particularly important.

Three-dimensional amide proton transfer-weighted and intravoxel incoherent motion imaging for predicting bone metastasis in patients with prostate cancer: A pilot study

PURPOSE

To explore the value of 3-dimensional amide proton transfer-weighted (APTw) and intravoxel incoherent motion (IVIM) imaging in predicting bone metastasis (BM) of prostate cancer (PCa) in addition to routine diffusion-weighted imaging (DWI).

METHODS

The clinical and imaging data of 39 PCa patients who were pathologically confirmed in our hospital from March 2019 to February 2022 were retrospectively analyzed, and they were divided into BM-negative (27 patients) and BM-positive (12 patients) groups. MR examination included APTw, DWI and IVIM imaging. The IVIM data was fitted by single-exponential IVIM model (IVIM_mono) and double-exponential IVIM model (IVIM_bi), respectively. The APTw, ADC, IVIM_mono (D_mono, D*_mono, and f_mono), and IVIM_bi (D_bi, D*_bi, and f_bi) parameters were independently measured by two radiologists. The synthetic minority oversampling technique (SMOTE) was conducted to balance the minority group. Mann-Whitney U test or Student's t-test was used to compare above values between the BM-negative and BM-positive groups. The diagnostic performance was evaluated with receiver operating characteristic (ROC) analysis of each parameter and their combination. The Delong test was used for ROC curve comparison.The relationship between APTw and IVIM was explored through Spearman's rank correlation analysis.

RESULTS

The APTw and D*_mono values were higher, and the ADC, f_mono, and f_bi values were lower in the BM-positive group than in the BM-negative group (all P < 0.05). Among the individual parameters, the AUC of f_mono was the highest (AUC = 0.865), and AUC (f_mono) was significantly higher than AUC (f_bi), AUC (D*_mono), and AUC (ADC) (all P < 0.05). The AUC (IVIM_mono) was higher than the AUC (IVIM_bi) (P = 0.0068). The combination of APTw and IVIM_mono further improved diagnostic capability, and the AUC of APTw+IVIM_mono was significantly higher than those of APTw and DWI (all P < 0.05). No correlation was found between IVIM-derived parameters and APTw value.

CONCLUSION

Both 3D APTw and IVIM imaging could predict BM of PCa. IVIM showed better performance than APTw and DWI, and the single-exponential IVIM model was superior to the double-exponential IVIM model. The combination of APTw and IVIM could further improve diagnostic performance.

Mapping of magnetic resonance imaging's transverse relaxation time at low signal-to-noise ratio using Bloch simulations and principal component analysis image denoising

High-resolution mapping of magnetic resonance imaging (MRI)'s transverse relaxation time (T₂ ) can benefit many clinical applications by offering improved anatomic details, enhancing the ability to probe tissues' microarchitecture, and facilitating the identification of early pathology. Increasing spatial resolutions, however, decreases data's signal-to-noise ratio (SNR), particularly at clinical scan times. This impairs imaging quality, and the accuracy of subsequent radiological interpretation. Recently, principal component analysis (PCA) was employed for denoising diffusion-weighted MR images and was shown to be effective for improving parameter estimation in multiexponential relaxometry. This study combines the Marchenko-Pastur PCA (MP-PCA) signal model with the echo modulation curve (EMC) algorithm for denoising multiecho spin-echo (MESE) MRI data and improving the precision of EMC-generated single T₂ relaxation maps. The denoising technique was validated on simulations, phantom scans, and in vivo brain and knee data. MESE scans were performed on a 3-T Siemens scanner. The acquired images were denoised using the MP-PCA algorithm and were then provided as input for the EMC T₂ -fitting algorithm. Quantitative analysis of the denoising quality included comparing the standard deviation and coefficient of variation of T₂ values, along with gold standard SNR estimation of the phantom scans. The presented denoising technique shows an increase in T₂ maps' precision and SNR, while successfully preserving the morphological features of the tissue. Employing MP-PCA denoising as a preprocessing step decreases the noise-related variability of T₂ maps produced by the EMC algorithm and thus increases their precision. The proposed method can be useful for a wide range of clinical applications by facilitating earlier detection of pathologies and improving the accuracy of patients' follow-up.

Comparison of single-shot EPI and multi-shot EPI in prostate DWI at 3.0 T

In prostate MRI, single-shot EPI (ssEPI) DWI still suffers from distortion and blurring. Multi-shot EPI (msEPI) overcomes the drawbacks of ssEPI DWI. The aim of this article was to compare the image quality and diagnostic performance for clinically significant prostate cancer (csPC) between ssEPI DWI and msEPI DWI. This retrospective study included 134 patients with suspected PC who underwent 3.0 T MRI and subsequent MRI-guided biopsy. Three radiologists independently assessed anatomical distortion, prostate edge clarity, and lesion conspicuity score for pathologically confirmed csPC. Lesion apparent diffusion coefficient (ADC) and benign ADC were also calculated. In 17 PC patients who underwent prostatectomy, three radiologists independently assessed eight prostate regions by DWI score in PI-RADS v 2.1. Anatomical distortion and prostate edge clarity were significantly higher in msEPI DWI than in ssEPI DWI in the three readers. Lesion conspicuity score was significantly higher in msEPI DWI than in ssEPI DWI in reader 1 and reader 3. Regarding discrimination ability between PC with GS ≤ 3 + 4 and PC with GS ≥ 4 + 3 using lesion ADC, AUC was comparable between ssEPI DWI and msEPI DWI. For diagnostic performance of csPC using DWI score, AUC was comparable between msEPI DWI and ssEPI DWI in all readers. Compared with ssEPI DWI, msEPI DWI had improved image quality and similar or higher diagnostic performance.

Emerging MR methods for improved diagnosis of prostate cancer by multiparametric MRI

Current challenges of using serum prostate-specific antigen (PSA) level-based screening, such as the increased false positive rate, inability to detect clinically significant prostate cancer (PCa) with random biopsy, multifocality in PCa, and the molecular heterogeneity of PCa, can be addressed by integrating advanced multiparametric MR imaging (mpMRI) approaches into the diagnostic workup of PCa. The standard method for diagnosing PCa is a transrectal ultrasonography (TRUS)-guided systematic prostate biopsy, but it suffers from sampling errors and frequently fails to detect clinically significant PCa. mpMRI not only increases the detection of clinically significant PCa, but it also helps to reduce unnecessary biopsies because of its high negative predictive value. Furthermore, non-Cartesian image acquisition and compressed sensing have resulted in faster MR acquisition with improved signal-to-noise ratio, which can be used in quantitative MRI methods such as dynamic contrast-enhanced (DCE)-MRI. With the growing emphasis on the role of pre-biopsy mpMRI in the evaluation of PCa, there is an increased demand for innovative MRI methods that can improve PCa grading, detect clinically significant PCa, and biopsy guidance. To meet these demands, in addition to routine T1-weighted, T2-weighted, DCE-MRI, diffusion MRI, and MR spectroscopy, several new MR methods such as restriction spectrum imaging, vascular, extracellular, and restricted diffusion for cytometry in tumors (VERDICT) method, hybrid multi-dimensional MRI, luminal water imaging, and MR fingerprinting have been developed for a better characterization of the disease. Further, with the increasing interest in combining MR data with clinical and genomic data, there is a growing interest in utilizing radiomics and radiogenomics approaches. These big data can also be utilized in the development of computer-aided diagnostic tools, including automatic segmentation and the detection of clinically significant PCa using machine learning methods.

MR fingerprinting of the prostate

Multiparametric magnetic resonance imaging (mpMRI) has been adopted as the key tool for detection, localization, characterization, and risk stratification of patients suspected to have prostate cancer. Despite advantages over systematic biopsy, the interpretation of prostate mpMRI has limitations including a steep learning curve, leading to considerable interobserver variation. There is growing interest in clinical translation of quantitative imaging techniques for more objective lesion assessment. However, traditional mapping techniques are slow, precluding their use in the clinic. Magnetic resonance fingerprinting (MRF) is an efficient approach for quantitative maps of multiple tissue properties simultaneously. The T₁ and T₂ values obtained with MRF have been validated with phantom studies as well as in normal volunteers and patients. Studies have shown that MRF-derived T₁ and T₂ along with ADC values are all significant independent predictors in the differentiation between normal prostate tissue and prostate cancer, and hold promise in differentiating low and intermediate/high-grade cancers. This review seeks to introduce the basics of the prostate MRF technique, discuss the potential applications of prostate MRF for the characterization of prostate cancer, and describes ongoing areas of research.

Can Pre-treatment Quantitative Multi-parametric MRI Predict the Outcome of Radiotherapy in Patients with Prostate Cancer?

RATIONALE AND OBJECTIVES

To investigate whether pre-treatment quantitative multiparametric MRI can predict biochemical outcome of prostate cancer (PCa) patients treated with primary radiotherapy (RT).

MATERIALS AND METHODS

Fifty-one patients with biopsy confirmed PCa underwent prostate multiparametric MRI on 3T MR scanner prior to RT. Thirty-seven men (73%) were treated with external beam RT alone, 12 men (24%) were treated with brachytherapy monotherapy, and two men (4%) were treated with external beam RT with brachytherapy boost. The index lesion was outlined by a radiologist and quantitative apparent diffusion coefficient (ADC), T2 and DCE parameters were measured. Biochemical failure was defined using the Phoenix criteria.

RESULTS

After a median follow-up of 65 months, seven patients had biochemical failure. ADC had an area under the receiver operating characteristic curve of 0.71 for predicting RT outcome with significantly lower ADC (0.78 ± 0.17 vs 0.96 ± 0.26 µm²/ms, p = 0.04) of the index lesion in men with biochemical failure. Ideal ADC cutoff point (Youdens index) was 0.96 µm²/ms which had a sensitivity of 100% and specificity of 48% for predicting biochemical failure. Kaplan-Meier analysis showed that lower ADC values were associated with significantly lower freedom from biochemical failure (FFBF, p = 0.03, no failures out of 20 men if ADC ≥ 0.96 µm²/ms; seven of 31 with failures if ADC < 0.96 µm²/ms). On multivariable analysis, ADC was associated with FFBF (HR 0.96 per increase in ADC of 0.01 um²/ms [95% CI, 0.92-1.00]; p = 0.042) after accounting for National Comprehensive Cancer Network risk category (p = 0.064) and receipt of androgen deprivation therapy (p = 0.141). Quantitative T2 and DCE parameters were not associated with biochemical outcome.

CONCLUSION

Our results suggest that quantitative ADC values of the index lesion may predict biochemical failure following primary radiotherapy in patients with PCa. Lower ADC values were associated with inferior biochemical control.

Synthetic MRI for Radiotherapy Planning for Brain and Prostate Cancers: Phantom Validation and Patient Evaluation

Purpose

We aimed to evaluate the accuracy of T₁ and T₂ mappings derived from a multispectral pulse sequence (magnetic resonance image compilation, MAGiC^®) on 1.5-T MRI and with conventional sequences [gradient echo with variable flip angle (GRE-VFA) and multi-echo spin echo (ME-SE)] compared to the reference values for the purpose of radiotherapy treatment planning.

Methods

The accuracy of T₁ and T₂ measurements was evaluated with 2 coils [head and neck unit (HNU) and BODY coils] on phantoms using descriptive statistics and Bland–Altman analysis. The reproducibility and repeatability of T₁ and T₂ measurements were performed on 15 sessions with the HNU coil. The T₁ and T₂ synthetic sequences obtained by both methods were evaluated according to quality assurance (QA) requirements for radiotherapy. T₁ and T₂in vivo measurements of the brain or prostate tissues of two groups of five subjects were also compared.

Results

The phantom results showed good agreement (mean bias, 8.4%) between the two measurement methods for T₁ values between 490 and 2,385 ms and T₂ values between 25 and 400 ms. MAGiC^® gave discordant results for T₁ values below 220 ms (bias with the reference values, from 38% to 1,620%). T₂ measurements were accurately estimated below 400 ms (mean bias, 8.5%) by both methods. The QA assessments are in agreement with the recommendations of imaging for contouring purposes for radiotherapy planning. On patient data of the brain and prostate, the measurements of T₁ and T₂ by the two quantitative MRI (qMRI) methods were comparable (max difference, <7%).

Conclusion

This study shows that the accuracy, reproducibility, and repeatability of the multispectral pulse sequence (MAGiC^®) were compatible with its use for radiotherapy treatment planning in a range of values corresponding to soft tissues. Even validated for brain imaging, MAGiC^® could potentially be used for prostate qMRI.

Rapid MR relaxometry using deep learning: An overview of current techniques and emerging trends

Quantitative mapping of MR tissue parameters such as the spin-lattice relaxation time (T₁ ), the spin-spin relaxation time (T₂ ), and the spin-lattice relaxation in the rotating frame (T_1ρ ), referred to as MR relaxometry in general, has demonstrated improved assessment in a wide range of clinical applications. Compared with conventional contrast-weighted (eg T₁ -, T₂ -, or T_1ρ -weighted) MRI, MR relaxometry provides increased sensitivity to pathologies and delivers important information that can be more specific to tissue composition and microenvironment. The rise of deep learning in the past several years has been revolutionizing many aspects of MRI research, including image reconstruction, image analysis, and disease diagnosis and prognosis. Although deep learning has also shown great potential for MR relaxometry and quantitative MRI in general, this research direction has been much less explored to date. The goal of this paper is to discuss the applications of deep learning for rapid MR relaxometry and to review emerging deep-learning-based techniques that can be applied to improve MR relaxometry in terms of imaging speed, image quality, and quantification robustness. The paper is comprised of an introduction and four more sections. Section 2 describes a summary of the imaging models of quantitative MR relaxometry. In Section 3, we review existing "classical" methods for accelerating MR relaxometry, including state-of-the-art spatiotemporal acceleration techniques, model-based reconstruction methods, and efficient parameter generation approaches. Section 4 then presents how deep learning can be used to improve MR relaxometry and how it is linked to conventional techniques. The final section concludes the review by discussing the promise and existing challenges of deep learning for rapid MR relaxometry and potential solutions to address these challenges.

T2 mapping for the characterization of prostate lesions

Purpose

Purpose of this study is to evaluate the diagnostic accuracy of quantitative T2/ADC values in differentiating between PCa and lesions showing non-specific inflammatory infiltrates and atrophy, features of chronic prostatitis, as the most common histologically proven differential diagnosis.

Methods

In this retrospective, single-center cohort study, we analyzed 55 patients suspected of PCa, who underwent mpMRI (3T) including quantitative T2 maps before robot-assisted mpMRI-TRUS fusion prostate biopsy. All prostate lesions were scored according to PI-RADS v2.1. Regions of interest (ROIs) were annotated in focal lesions and normal prostate tissue. Quantitative mpMRI values from T2 mapping and ADC were compared using two-tailed t tests. Receiver operating characteristic curves (ROCs) and cutoff were calculated to differentiate between PCa and chronic prostatitis.

Results

Focal lesions showed significantly lower ADC and T2 mapping values than normal prostate tissue (p < 0.001). PCa showed significantly lower ADC and T2 values than chronic prostatitis (p < 0.001). ROC analysis revealed areas under the receiver operating characteristic curves (AUCs) of 0.85 (95% CI 0.74–0.97) for quantitative ADC values and 0.84 (95% CI 0.73–0.96) for T2 mapping. A significant correlation between ADC and T2 values was observed (r = 0.70; p < 0.001).

Conclusion

T2 mapping showed high diagnostic accuracy for differentiating between PCa and chronic prostatitis, comparable to the performance of ADC values.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-03991-8.

Magnetic resonance fingerprinting in prostate cancer before and after contrast enhancement

OBJECTIVES

To assess the apparent diffusion coefficient (ADC) values and the T1 and T2 values derived from nonenhanced (NE) and contrast-enhanced (CE) magnetic resonance fingerprinting (MRF) in the prostate gland and to evaluate differences in values among prostate cancer, the normal peripheral zone (PZ) and the normal transition zone (TZ).

METHODS

Fifty-seven patients (median age, 73 years; range, 48-86) with prostate cancer who underwent multiparametric MRI including NE and CE MRF were included in this study. T1 and T2 values were extracted from NE and CE MRF, respectively. Five quantitative values (the ADC, NE T1, NE T2, CE T1 and CE T2 values) were measured in three areas: prostate cancer, PZ and TZ. We compared the values among the three areas and evaluated the differences between NE MRF and CE MRF values.

RESULTS

ADC values and MRF-derived values were significantly higher in PZ than prostate cancer or TZ (p < 0.001). TZ had a significantly lower CE T1 but significantly higher values of the other variables than prostate cancer (p < 0.001). The T1 values in all three areas and the T2 values in prostate cancer and TZ were significantly lower on CE MRF than on NE MRF (p < 0.001).

CONCLUSIONS

Quantitative analysis of NE and CE MRI can be conducted by using the MRF technique. The ADC value and the T1 and T2 values from CE MRF and NE MRF were found to be significantly different between prostate cancer and normal prostate tissue.

ADVANCES IN KNOWLEDGE

The T1 and T2 values from contrast-enhanced MR fingerprinting are significantly different between prostate cancer and normal prostate tissue.

Value of T2 Mapping MRI for Prostate Cancer Detection and Classification

BACKGROUND

Currently, multi-parametric prostate MRI (mpMRI) consists of a qualitative T₂ , diffusion weighted, and dynamic contrast enhanced imaging. Quantification of T₂ imaging might further standardize PCa detection and support artificial intelligence solutions.

PURPOSE

To evaluate the value of T₂ mapping to detect prostate cancer (PCa) and to differentiate PCa aggressiveness.

STUDY TYPE

Retrospective single center cohort study.

POPULATION

Forty-four consecutive patients (mean age 67 years; median PSA 7.9 ng/mL) with mpMRI and verified PCa by subsequent targeted plus systematic MR/ultrasound (US)-fusion biopsy from February 2019 to December 2019.

FIELD STRENGTH/SEQUENCE

Standardized mpMRI at 3 T with an additionally acquired T₂ mapping sequence.

ASSESSMENT

Primary endpoint was the analysis of quantitative T₂ values and contrast differences/ratios (CD/CR) between PCa and benign tissue. Secondary objectives were the correlation between T₂ values, ISUP grade, apparent diffusion coefficient (ADC) value, and PI-RADS, and the evaluation of thresholds for differentiating PCa and clinically significant PCa (csPCa).

STATISTICAL TESTS

Mann-Whitney test, Spearman's rank (r_s ) correlation, receiver operating curves, Youden's index (J), and AUC were performed. Statistical significance was defined as P < 0.05.

RESULTS

Median quantitative T₂ values were significantly lower for PCa in PZ (85 msec) and PCa in TZ (75 msec) compared to benign PZ (141 msec) or TZ (97 msec) (P < 0.001). CD/CR between PCa and benign PZ (51.2/1.77), respectively TZ (19.8/1.29), differed significantly (P < 0.001). The best T₂ -mapping threshold for PCa/csPCa detection was for TZ 81/86 msec (J = 0.929/1.0), and for PZ 110 msec (J = 0.834/0.905). Quantitative T₂ values of PCa did not correlate significantly with the ISUP grade (r_s  = 0.186; P = 0.226), ADC value (r_s  = 0.138; P = 0.372), or PI-RADS (r_s  = 0.132; P = 0.392).

DATA CONCLUSION

Quantitative T₂ values could differentiate PCa in TZ and PZ and might support standardization of mpMRI of the prostate. Different thresholds seem to apply for PZ and TZ lesions. However, in the present study quantitative T₂ values were not able to indicate PCa aggressiveness.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

Validation of Prostate Tissue Composition by Using Hybrid Multidimensional MRI: Correlation with Histologic Findings

Background Tissue estimates obtained by using microstructure imaging techniques, such as hybrid multidimensional (HM) MRI, may improve prostate cancer diagnosis but require histologic validation. Purpose To validate prostate tissue composition measured by using HM MRI, with quantitative histologic evaluation from whole-mount prostatectomy as the reference standard. Materials and Methods In this HIPAA-compliant study, from December 2016 to July 2018, prospective participants with biopsy-confirmed prostate cancer underwent 3-T MRI before radical prostatectomy. Axial HM MRI was performed with all combinations of echo times (57, 70, 150, and 200 msec) and b values (0, 150, 750, and 1500 sec/mm²). Data were fitted by using a three-compartment signal model to generate volumes for each tissue component (stroma, epithelium, lumen). Quantitative histologic evaluation was performed to calculate volume fractions for each tissue component for regions of interest corresponding to MRI. Tissue composition measured by using HM MRI and quantitative histologic evaluation were compared (paired t test) and correlated (Pearson correlation coefficient), and agreement (concordance correlation) was assessed. Receiver operating characteristic curve analysis for cancer diagnosis was performed. Results Twenty-five participants (mean age, 60 years ± 7 [standard deviation]; 30 cancers and 45 benign regions of interest) were included. Prostate tissue composition measured with HM MRI and quantitative histologic evaluation did not differ (stroma, 45% ± 11 vs 44% ± 11 [P = .23]; epithelium, 31% ± 15 vs 34% ± 15 [P = .08]; and lumen, 24% ± 13 vs 22% ± 11 [P = .80]). Between HM MRI and histologic evaluation, there was excellent correlation (Pearson r: overall, 0.91; stroma, 0.82; epithelium, 0.93; lumen, 0.90 [all P < .05]) and agreement (concordance correlation coefficient: overall, 0.91; stroma, 0.81; epithelium, 0.90; and lumen, 0.87). High areas under the receiver operating characteristic curve obtained with HM MRI (0.96 for epithelium and 0.94 for lumen, P < .001) and histologic evaluation (0.94 for epithelium and 0.88 for lumen, P < .001) were found for differentiation between benign tissue and prostate cancer. Conclusion Tissue composition measured by using hybrid multidimensional MRI had excellent correlation with quantitative histologic evaluation as the reference standard. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Muglia in this issue.

Utility of Quantitative T2-Mapping Compared to Conventional and Advanced Diffusion Weighted Imaging Techniques for Multiparametric Prostate MRI in Men with Hip Prosthesis

BACKGROUND

Diffusion weighted imaging (DWI) is fundamental for prostate cancer (PCa) detection with MRI; however, limited by susceptibility artifact from hip prosthesis.

PURPOSE

To evaluate image quality and ability to detect PCa with quantitative T2-mapping and DWI in men with hip prosthesis undergoing prostate MRI.

STUDY TYPE

Prospective, cross-sectional study.

POPULATION

Thirty consecutive men with hip replacement (18 unilateral, 12 bilateral) undergoing prostate MRI from 2019 to 2021.

FIELD STRENGTH/SEQUENCE

3-T; multiparametric MRI (T2W, DCE-MRI, echo-planar [EPI]-DWI), T2-mapping (Carr-Purcell-Meiboom-Gill), FOCUS-EPI-DWI, PROPELLER-DWI.

ASSESSMENT

Five blinded radiologists independently evaluated MRI image quality using a 5-point Likert scale. PI-RADS v2.1 scores were applied in four interpretation strategies: 1) T2W-FSE+DCE-MRI+EPI-DWI, 2) T2W-FSE+DCE-MRI+EPI-DWI+FOCUS-EPI-DWI, 3) T2W-FSE+DCE-MRI+EPI-DWI+PROPELLER-DWI, 4) T2W-FSE+DCE-MRI+EPI-DWI+T2-maps. Five-point confidence scores were recorded.

STATISTICAL ANALYSIS

ANOVA, Kruskal-Wallis with pair-wise comparisons by Wilcoxon sign-rank, and paired t-tests, P < 0.05 was considered significant. Cohen's Kappa (k) for PI-RADSv2.1 scoring and proportion of correctly classified lesions tabulated for pathology-confirmed cases with 95% confidence intervals (CIs).

RESULTS

For all radiologists, T2-map image quality was significantly higher than EPI-DWI, FOCUS-EPI-DWI, and PROPELLER-DWI and similar (P = 0.146-0.706) or significantly better (for two readers) than T2W-FSE and DCE-MRI. PI-RADS v2.1 agreement improved comparing strategy A (k = 0.46) to strategy B (k = 0.58) to strategy C (k = 0.58) and was highest with strategy D which included T2-maps (k = 1.00). Radiologists' confidence was significantly highest with strategy D. Strategies B and C had similar confidence (P = 0.051-0.063) both significantly outperforming strategy A. Twelve men with 17 lesions had pathology confirmed diagnoses (13 PCa, 4 benign). Strategy D had the highest proportion of correctly classified lesions (76.5-82.4%) with overlapping 95% confidence intervals.

DATA CONCLUSION

T2-mapping may be a valuable adjunct to prostate MRI in men with hip replacement resulting in improved image quality, higher reader confidence, interobserver agreement, and accuracy in PI-RADS scoring.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Artificial intelligence and imaging biomarkers for prostate radiation therapy during and after treatment

Magnetic resonance imaging (MRI) is increasingly used in the management of prostate cancer (PCa). Quantitative MRI (qMRI) parameters, derived from multi-parametric MRI, provide indirect measures of tumour characteristics such as cellularity, angiogenesis and hypoxia. Using Artificial Intelligence (AI), relevant information and patterns can be efficiently identified in these complex data to develop quantitative imaging biomarkers (QIBs) of tumour function and biology. Such QIBs have already demonstrated potential in the diagnosis and staging of PCa. In this review, we explore the role of these QIBs in monitoring treatment response during and after PCa radiotherapy (RT). Recurrence of PCa after RT is not uncommon, and early detection prior to development of metastases provides an opportunity for salvage treatments with curative intent. However, the current method of monitoring treatment response using prostate-specific antigen levels lacks specificity. QIBs, derived from qMRI and developed using AI techniques, can be used to monitor biological changes post-RT providing the potential for accurate and early diagnosis of recurrent disease.

Feasibility of Novel Three-Dimensional Magnetic Resonance Fingerprinting of the Prostate Gland: Phantom and Clinical Studies

Objective

To evaluate the feasibility of a new three-dimensional (3D) MR fingerprinting (MRF) technique for the prostate gland by conducting phantom and clinical studies.

Materials and Methods

The new 3D MRF technique used in this study enables quick data acquisition and has a high resolution. For the phantom study, the MRF T1 and T2 values in an in-house phantom were compared with those of gold-standard mapping methods using linear regression analysis. For the clinical study, we evaluated 90 patients who underwent prostate imaging with MRF for suspected prostate cancer between September 2019 and February 2020. The mean T1 and T2 values were compared in the peripheral zone, transition zone, and focal lesions using paired t tests. The differences in the T1 and T2 values according to cancer aggressiveness were evaluated using one-way analysis of variance.

Results

In the phantom study, the MRF T1 and T2 values showed a perfect correlation with the gold-standard T1 and T2 values (R > 0.99). In the clinical study, the T1 and T2 values in the peripheral zone were significantly higher than those in the transitional zone (p < 0.001, both). The T1 and T2 values in prostate cancer were significantly lower than those in the peripheral and transitional zones. The higher the grade of cancer, the lower the T2 values.

Conclusion

The T1 and T2 values obtained from the 3D MRF showed a perfect correlation with the gold standard values in the phantom study. Differences in the T1 and T2 values among the different zones of the prostate gland were identified using 3D MRF in patients.

New prostate MRI techniques and sequences

Prostate MRI has seen increasing interest in recent years and has led to the development of new MRI techniques and sequences to improve prostate cancer (PCa) diagnosis which are reviewed in this article. Numerous studies have focused on improving image quality (segmented DWI) and faster acquisition (compressed sensing, k-t-SENSE, PROPELLER). An increasing number of studies have developed new quantitative and computer-aided diagnosis methods including artificial intelligence (PROSTATEx challenge) that mitigate the subjective nature of mpMRI interpretation. MR fingerprinting allows rapid, simultaneous generation of quantitative maps of multiple physical properties (T1, T2), where PCa are characterized by lower T1 and T2 values. New techniques like luminal water imaging (LWI), restriction spectrum imaging (RSI), VERDICT and hybrid multi-dimensional MRI (HM-MRI) have been developed for microstructure imaging, which provide information similar to histology. The distinct MR properties of tissue components and their change with the presence of cancer is used to diagnose prostate cancer. LWI is a T2-based imaging technique where long T2-component corresponding to luminal water is reduced in PCa. RSI and VERDICT are diffusion-based techniques where PCa is characterized by increased signal from intra-cellular restricted water and increased intracellular volume fraction, respectively, due to increased cellularity. VERDICT also reveal loss of extracellular-extravascular space in PCa due to loss of glandular structure. HM-MRI measures volumes of prostate tissue components, where PCa has reduced lumen and stromal and increased epithelium volume similar to results shown in histology. Similarly, molecular imaging using hyperpolarized ¹³C imaging has been utilized.

Effect of Echo Times on Prostate Cancer Detection on T2-Weighted Images

PURPOSE

To compare the effect of different echo times (TE) on the detection of prostate cancer (PCa) on T2-weighted MR images.

MATERIALS AND METHODS

This study recruited patients (n = 38) with histologically confirmed PCa who underwent preoperative 3T MRI. Three radiologists independently marked region on interests (ROIs) on suspected PCa lesions on T2-weighted images at different TEs: 90, 150, and 180 ms obtained with Turbo Spin Echo imaging protocol with multiple echoes. The ROIs were assigned a value 1-5 indicating the reviewer's confidence in accurately detecting PCa. These ROIs were compared to histologically confirmed PCa (n = 95) on whole mount prostatectomy sections to calculate sensitivity, positive predictive value (PPV), and confidence score.

RESULTS

Two radiologists (R1, R2) showed significantly increased sensitivity for PCa detection at 180 ms TE compared to 90 ms (R1: 43.2, 50.5, 50.5%, R2: 45.3, 44.2, 53.7% at TE of 90, 150, 180 ms, respectively) (p = 0.048, 0.033 for R1 and R2). Sensitivity was similar for radiologist 3 (45.3%-46.3%) at different TE values (p = 0.953). No significant difference in the PPV (R1: 64.1%-70.6%, R2: 46.7%-56.0%, R3: 70.5%-81.5%) and the confidence score assigned (R1: 4.6-4.8, R2: 4.6-4.8 R3: 4.3-4.4) was found for either of the radiologists.

CONCLUSION

Our results suggest improved detection of PCa with similar PPV and confidence scores when higher TE values are utilized for T2-weighted image acquisition.

Clinical utility of combined T2-weighted imaging and T2-mapping in the detection of prostate cancer: a multi-observer study

Background

To evaluate the clinical utility of combined T2-weighted imaging and T2-mapping for the detection of prostate cancer.

Methods

Forty patients underwent multiparametric magnetic resonance imaging (mpMRI) and T2-mapping of the prostate. Three readers each reviewed two sets of images: T2-weighted fast spin-echo (FSE) sequence (standard T2), and standard T2 in combination with T2-mapping. Each reader assigned probability scores for malignancy to each zone [peripheral zone (PZ) or transition zone (TZ)]. Inter-observer variability for standard T2 and combined standard T2 with T2-mapping were assessed. Diagnostic accuracy was compared between standard T2 and combined standard T2 with T2-mapping.

Results

There was fair agreement between all three readers for standard T2 [intraclass correlation coefficient (ICC) =0.56] and combined standard T2 with T2-mapping (ICC =0.58). There was no significant difference in the area under the receiver operator characteristics curve for standard T2 compared to combined standard T2 with T2-mapping (0.89 vs. 0.82, P=0.31). Sensitivity (Sn) for combined standard T2 with T2-mapping was significantly higher compared to standard T2 alone (73.0% vs. 49.2%, P=0.006). Specificity (Sp) for combined standard T2 with T2-mapping was borderline significantly lower compared to standard T2 alone (89.3% vs. 94.9%, P=0.05). There was no significant differences between the negative predictive values (NPVs) and positive predictive values (PPVs) (P=0.07, P=0.45).

Conclusions

Combination of T2-weighted imaging and T2-mapping could potentially increase Sn for prostate malignancy compared to T2-weighted imaging alone.

Targeted Biopsy Validation of Peripheral Zone Prostate Cancer Characterization With Magnetic Resonance Fingerprinting and Diffusion Mapping

OBJECTIVE

This study aims for targeted biopsy validation of magnetic resonance fingerprinting (MRF) and diffusion mapping for characterizing peripheral zone (PZ) prostate cancer and noncancers.

MATERIALS AND METHODS

One hundred four PZ lesions in 85 patients who underwent magnetic resonance imaging were retrospectively analyzed with apparent diffusion coefficient (ADC) mapping, MRF, and targeted biopsy (cognitive or in-gantry). A radiologist blinded to pathology drew regions of interest on targeted lesions and visually normal peripheral zone on MRF and ADC maps. Mean T1, T2, and ADC were analyzed using linear mixed models. Generalized estimating equations logistic regression analyses were used to evaluate T1 and T2 relaxometry combined with ADC in differentiating pathologic groups.

RESULTS

Targeted biopsy revealed 63 cancers (low-grade cancer/Gleason score 6 = 10, clinically significant cancer/Gleason score ≥7 = 53), 15 prostatitis, and 26 negative biopsies. Prostate cancer T1, T2, and ADC (mean ± SD, 1660 ± 270 milliseconds, 56 ± 20 milliseconds, 0.70 × 10 ± 0.24 × 10 mm/s) were significantly lower than prostatitis (mean ± SD, 1730 ± 350 milliseconds, 77 ± 36 milliseconds, 1.00 × 10 ± 0.30 × 10 mm/s) and negative biopsies (mean ± SD, 1810 ± 250 milliseconds, 71 ± 37 milliseconds, 1.00 × 10 ± 0.33 × 10 mm/s). For cancer versus prostatitis, ADC was sensitive and T2 specific with comparable area under curve (AUC; (AUCT2 = 0.71, AUCADC = 0.79, difference between AUCs not significant P = 0.37). T1 + ADC (AUCT1 + ADC = 0.83) provided the best separation between cancer and negative biopsies. Low-grade cancer T2 and ADC (mean ± SD, 75 ± 29 milliseconds, 0.96 × 10 ± 0.34 × 10 mm/s) were significantly higher than clinically significant cancers (mean ± SD, 52 ± 16 milliseconds, 0.65 ± 0.18 × 10 mm/s), and T2 + ADC (AUCT2 + ADC = 0.91) provided the best separation.

CONCLUSIONS

T1 and T2 relaxometry combined with ADC mapping may be useful for quantitative characterization of prostate cancer grades and differentiating cancer from noncancers for PZ lesions seen on T2-weighted images.

Use of quantitative T2 mapping for the assessment of renal cell carcinomas: first results

Background

Correct staging and grading of patients with clear cell renal cell carcinoma (cRCC) is of clinical relevance for the prediction of operability and for individualized patient management. As partial or radial resection with postoperative tumor grading currently remain the methods of choice for the classification of cRCC, non-invasive preoperative alternatives to differentiate lower grade from higher grade cRCC would be beneficial.

Methods

This institutional-review-board approved cross-sectional study included twenty-seven patients (8 women, mean age ± SD, 61.3 ± 14.2) with histopathologically confirmed cRCC, graded according to the International Society of Urological Pathology (ISUP). A native, balanced steady-state free precession T2 mapping sequence (TrueFISP) was performed at 1.5 T. Quantitative T2 values were measured with circular 2D ROIs in the solid tumor portion and also in the normal renal parenchyma (cortex and medulla). To estimate the optimal cut-off T2 value for identifying lower grade cRCC, a Receiver Operating Characteristic Curve (ROC) analysis was performed and sensitivity and specificity were calculated. Students’ t-tests were used to evaluate the differences in mean values for continuous variables, while intergroup differences were tested for significance with two-tailed Mann-Whitney-U tests.

Results

There were significant differences between the T2 values for lower grade (ISUP 1–2) and higher grade (ISUP 3–4) cRCC (p < 0.001), with higher T2 values for lower grade cRCC compared to higher grade cRCC. The sensitivity and specificity for the differentiation of lower grade from higher grade tumors were 83.3% (95% CI: 0.59–0.96) and 88.9% (95% CI: 0.52–1.00), respectively, using a threshold value of ≥110 ms. Intraobserver/interobserver agreement for T2 measurements was excellent/substantial.

Conclusions

Native T2 mapping based on a balanced steady-state free precession MR sequence might support an image-based distinction between lower and higher grade cRCC in a two-tier-system and could be a helpful addition to multiparametric imaging.

Electronic supplementary material

The online version of this article (10.1186/s40644-019-0222-8) contains supplementary material, which is available to authorized users.