Implementation of a 5-Minute Magnetic Resonance Imaging Screening Protocol for Prostate Cancer in Men With Elevated Prostate-Specific Antigen Before Biopsy

Ultra-high gradient performance 3-Tesla MRI for super-fast and high-quality prostate imaging: initial experience

OBJECTIVES

To implement and evaluate a super-fast and high-quality biparametric MRI (bpMRI) protocol for prostate imaging acquired at a new ultra-high gradient 3.0-T MRI system.

METHODS

Participants with clinically suspected prostate cancer prospectively underwent a multiparametric MRI (mpMRI) on a new 3.0-T MRI scanner (maximum gradient strength: 200 mT/m, maximum slew rate: 200 T/m/s). The bpMRI protocol was extracted from the full mpMRI protocol, including axial T2-weighted and diffusion-weighted (DWI) sequences (b0/800, b1500). Overall image quality was rated by two readers on a five-point Likert scale from (1) non-diagnostic to (5) excellent. PI-RADS 2.1 scores were assessed by three readers separately for the bpMRI and mpMRI protocols. Cohen's and Fleiss' κ were calculated for PI-RADS agreement between protocols and interrater reliability between readers, respectively.

RESULTS

Seventy-seven male participants (mean age, 66 ± 8 years) were included. Acquisition time of the bpMRI protocol was reduced by 62% (bpMRI: 5 min, 33 ± 21 s; mpMRI: 14 min, 50 ± 42 s). The bpMRI protocol showed excellent overall image quality for both the T2-weighted (median score both readers: 5 [IQR: 4-5]) and DWI (b1500) sequence (median score reader 1: 4 [IQR: 4-5]; reader 2: 4 [IQR: 4-4]). PI-RADS score agreement between protocols was excellent (Cohen's κ range: 0.91-0.95 [95% CI: 0.89, 0.99]) with an overall good interrater reliability (Fleiss' κ, 0.86 [95% CI: 0.80, 0.92]).

CONCLUSION

Ultra-high gradient MRI allows the establishment of a high-quality and rapidly acquired bpMRI with high PI-RADS agreement to a full mpMRI protocol.

TRIALS REGISTRATION

Clinicaltrials.gov, NCT06244680, Registered 06 February 2024, retrospectively registered, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT06244680 .

CRITICAL RELEVANCE STATEMENT

A novel 3.0-Tesla MRI system with an ultra-high gradient performance enabled high-quality biparametric prostate MRI in 5.5 min while achieving excellent PI-RADS agreement with a standard multiparametric protocol.

KEY POINTS

Multi- and biparametric prostate MRIs were prospectively acquired utilizing a maximum gradient of 200 mT/m. Super-fast biparametric MRIs showed excellent image quality and had high PI-RADS agreement with multiparametric MRIs. Implementation of high gradient MRI in clinical routine allows accelerated and high-quality biparametric prostate examinations.

Recent Developments in Speeding up Prostate MRI

The increasing incidence of prostate cancer cases worldwide has led to a tremendous demand for multiparametric MRI (mpMRI). In order to relieve the pressure on healthcare, reducing mpMRI scan time is necessary. This review focuses on recent techniques proposed for faster mpMRI acquisition, specifically shortening T2W and DWI sequences while adhering to the PI-RADS (Prostate Imaging Reporting and Data System) guidelines. Speeding up techniques in the reviewed studies rely on more efficient sampling of data, ranging from the acquisition of fewer averages or b-values to adjustment of the pulse sequence. Novel acquisition methods based on undersampling techniques are often followed by suitable reconstruction methods typically incorporating synthetic priori information. These reconstruction methods often use artificial intelligence for various tasks such as denoising, artifact correction, improvement of image quality, and in the case of DWI, for the generation of synthetic high b-value images or apparent diffusion coefficient maps. Reduction of mpMRI scan time is possible, but it is crucial to maintain diagnostic quality, confirmed through radiological evaluation, to integrate the proposed methods into the standard mpMRI protocol. Additionally, before clinical integration, prospective studies are recommended to validate undersampling techniques to avoid potentially inaccurate results demonstrated by retrospective analysis. This review provides an overview of recently proposed techniques, discussing their implementation, advantages, disadvantages, and diagnostic performance according to PI-RADS guidelines compared to conventional methods. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 3.

Abbreviated MRI Protocols in the Abdomen and Pelvis

Abbreviated MRI (AMRI) protocols rely on the acquisition of a limited number of sequences tailored to a specific question. The main objective of AMRI protocols is to reduce exam duration and costs, while maintaining an acceptable diagnostic performance. AMRI is of increasing interest in the radiology community; however, challenges limiting clinical adoption remain. In this review, we will address main abdominal and pelvic applications of AMRI in the liver, pancreas, kidney, and prostate, including diagnostic performance, pitfalls, limitations, and cost effectiveness will also be discussed. Level of Evidence: 3 Technical Efficacy Stage: 3.

Deep Learning Super-Resolution Reconstruction for Fast and Motion-Robust T2-weighted Prostate MRI

Background Deep learning (DL) reconstructions can enhance image quality while decreasing MRI acquisition time. However, DL reconstruction methods combined with compressed sensing for prostate MRI have not been well studied. Purpose To use an industry-developed DL algorithm to reconstruct low-resolution T2-weighted turbo spin-echo (TSE) prostate MRI scans and compare these with standard sequences. Materials and Methods In this prospective study, participants with suspected prostate cancer underwent prostate MRI with a Cartesian standard-resolution T2-weighted TSE sequence (T2C) and non-Cartesian standard-resolution T2-weighted TSE sequence (T2NC) between August and November 2022. Additionally, a low-resolution Cartesian DL-reconstructed T2-weighted TSE sequence (T2DL) with compressed sensing DL denoising and resolution upscaling reconstruction was acquired. Image sharpness was assessed qualitatively by two readers using a five-point Likert scale (from 1 = nondiagnostic to 5 = excellent) and quantitatively by calculating edge rise distance. The Friedman test and one-way analysis of variance with post hoc Bonferroni and Tukey tests, respectively, were used for group comparisons. Prostate Imaging Reporting and Data System (PI-RADS) score agreement between sequences was compared by using Cohen κ. Results This study included 109 male participants (mean age, 68 years ± 8 [SD]). Acquisition time of T2DL was 36% and 29% lower compared with that of T2C and T2NC (mean duration, 164 seconds ± 20 vs 257 seconds ± 32 and 230 seconds ± 28; P < .001 for both). T2DL showed improved image sharpness compared with standard sequences using both qualitative (median score, 5 [IQR, 4-5] vs 4 [IQR, 3-4] for T2C and 4 [IQR, 3-4] for T2NC; P < .001 for both) and quantitative (mean edge rise distance, 0.75 mm ± 0.39 vs 1.15 mm ± 0.68 for T2C and 0.98 mm ± 0.65 for T2NC; P < .001 and P = .01) methods. PI-RADS score agreement between T2NC and T2DL was excellent (κ range, 0.92-0.94 [95% CI: 0.87, 0.98]). Conclusion DL reconstruction of low-resolution T2-weighted TSE sequences enabled accelerated acquisition times and improved image quality compared with standard acquisitions while showing excellent agreement with conventional sequences for PI-RADS ratings. Clinical trial registration no. NCT05820113 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Turkbey in this issue.

Perceived patient burden and acceptability of MRI in comparison to PSA and ultrasound: results from the IP1-PROSTAGRAM study

BACKGROUND

The IP1-PROSTAGRAM study showed that a short, non-contrast MRI detected more significant cancers with similar rates of biopsy compared to PSA. Herein, we compare the expected and perceived burden of PSA, MRI and ultrasound as screening tests.

METHODS

IP1-PROSTAGRAM was a prospective, population-based, paired screening study of 408 men conducted at seven UK primary care practices and two imaging centres. The screening tests were serum PSA, non-contrast MRI and ultrasound. If any test was screen-positive, a prostate biopsy was performed. Participants completed an Expected Burden Questionnaire (EBQ) and Perceived Burden Questionnaire (PBQ) before and after each screening test.

RESULTS

The overall level of burden for MRI and PSA was minimal. Few men reported high levels of anxiety, burden, embarrassment or pain following either MRI or PSA. Participants indicated an overall preference for MRI after completing all screening tests. Of 408 participants, 194 (47.5%) had no preference, 106 (26.0%) preferred MRI and 79 (19.4%) preferred PSA. This indicates that prior to screening, participants preferred MRI compared to PSA (+6.6%, 95% CI 4.4-8.4, p = 0.02) and after completing screening, the preference for MRI was higher (+21.1%, 95% CI 14.9-27.1, p < 0.001). The proportion of participants who strongly agreed with repeating the test was 50.5% for ultrasound, 65% for MRI and 68% for PSA. A larger proportion of participants found ultrasound anxiety-inducing, burdensome, embarrassing and painful compared to both MRI and PSA.

CONCLUSIONS

Prostagram MRI and PSA are both acceptable as screening tests among men aged 50-69 years. Both tests were associated with minimal amounts of anxiety, burden, embarrassment and pain. The majority of participants preferred MRI over PSA and ultrasound.

REGISTRATION

This study was registered on clinicaltrials.gov at https://clinicaltrials.gov/ct2/show/NCT03702439 .

T2 Turbo Spin Echo With Compressed Sensing and Propeller Acquisition (Sampling k-Space by Utilizing Rotating Blades) for Fast and Motion Robust Prostate MRI: Comparison With Conventional Acquisition

OBJECTIVES

The aim of this study was to compare a new compressed sensing (CS) method for T2-weighted propeller acquisitions (T2 CS ) with conventional T2-weighted propeller sequences (T2 conv ) in terms of achieving a higher image quality, while reducing the acquisition time.

MATERIALS AND METHODS

Male participants with a clinical suspicion of prostate cancer were prospectively enrolled and underwent prostate magnetic resonance imaging at 3 T. Axial and sagittal images of the T2 conv sequence and the T2 CS sequence were acquired. Sequences were qualitatively assessed by 2 blinded radiologists concerning artifacts, image-sharpness, lesion conspicuity, capsule delineation, and overall image quality using 5-point Likert items ranging from 1 (nondiagnostic) to 5 (excellent). The apparent signal-to-noise ratio and apparent contrast-to-noise ratio were evaluated. PI-RADS scores were assessed for both sequences. Statistical analysis was performed by using Wilcoxon signed rank test and paired samples t test. Intrarater and interrater reliability of qualitative image evaluation was assessed using intraclass correlation coefficient (ICC) estimates.

RESULTS

A total of 29 male participants were included (mean age, 66 ± 8 years). The acquisition time of the T2 CS sequence was respectively 26% (axial plane) and 24% (sagittal plane) shorter compared with the T2 conv sequence (eg, axial: 171 vs 232 seconds; P < 0.001). In the axial plane, the T2 CS sequence had fewer artifacts (4 [4-4.5] vs 4 [3-4]; P < 0.001), better image-sharpness (4 [4-4.5] vs 3 [3-3.5]; P < 0.001), better capsule delineation (4 [3-4] vs 3 [3-3.5]; P < 0.001), and better overall image quality (4 [4-4] vs 4 [3-4]; P < 0.001) compared with the T2 conv sequence. The ratings of lesion conspicuity were similar (4 [4-4] vs 4 [3-4]; P = 0.166). In the sagittal plane, the T2 CS sequence outperformed the T2 conv sequence in the categories artifacts (4 [4-4] vs 3 [3-4]; P < 0.001), image sharpness (4 [4-5] vs 4 [3-4]; P < 0.001), lesion conspicuity (4 [4-4] vs 4 [3-4]; P = 0.002), and overall image quality (4 [4-4] vs 4 [3-4]; P = 0.002). Capsule delineation was similar between both sequences (3 [3-4] vs 3 [3-3]; P = 0.07). Intraobserver and interobserver reliability for qualitative scoring were good (ICC intra: 0.92; ICC inter: 0.86). Quantitative analysis revealed a higher apparent signal-to-noise ratio (eg, axial: 52.2 ± 9.7 vs 22.8 ± 3.6; P < 0.001) and a higher apparent contrast-to-noise ratio (eg, axial: 44.0 ± 9.6 vs 18.6 ± 3.7; P ≤ 0.001) of the T2 CS sequence. PI-RADS scores were the same for both sequences in all participants.

CONCLUSIONS

CS-accelerated T2-weighted propeller acquisition had a superior image quality compared with conventional T2-weighted propeller sequences while significantly reducing the acquisition time.

Prospectively Accelerated T2-Weighted Imaging of the Prostate by Combining Compressed SENSE and Deep Learning in Patients with Histologically Proven Prostate Cancer

BACKGROUND

To assess the performance of prospectively accelerated and deep learning (DL) reconstructed T2-weighted (T2w) imaging in volunteers and patients with histologically proven prostate cancer (PCa).

METHODS

Prospectively undersampled T2w datasets were acquired with acceleration factors of 1.7 (reference), 3.4 and 4.8 in 10 healthy volunteers and 23 patients with histologically proven PCa. Image reconstructions using compressed SENSE (C-SENSE) and a combination of C-SENSE and DL-based artificial intelligence (C-SENSE AI) were analyzed. Qualitative image comparison was performed using a 6-point Likert scale (overall image quality, noise, motion artifacts, lesion detection, diagnostic certainty); the T2 and PI-RADS scores were compared between the two reconstructions. Additionally, quantitative image parameters were assessed (apparent SNR, apparent CNR, lesion size, line profiles).

RESULTS

All C-SENSE AI-reconstructed images received a significantly higher qualitative rating compared to the C-SENSE standard images. Analysis of the quantitative parameters supported this finding, with significantly higher aSNR and aCNR. The line profiles demonstrated a significantly steeper signal change at the border of the prostatic lesion and the adjacent normal tissue in the C-SENSE AI-reconstructed images, whereas the T2 and PI-RADS scores as well as the lesion size did not differ.

CONCLUSION

In this prospective study, we demonstrated the clinical feasibility of a novel C-SENSE AI reconstruction enabling a 58% acceleration in T2w imaging of the prostate while obtaining significantly better image quality.

Comparison of Multiparametric and Fast MRI Protocols in Detecting Clinically Significant Prostate Cancer and a Detailed Cost Analysis

BACKGROUND

Due to the long acquisition time and high cost of multiparametric magnetic resonance imaging (mpMRI), biparametric and, more recently, fast prostate magnetic resonance imaging (fpMRI) protocols have been described. However, there is insufficient data about the diagnostic performance and cost of fpMRI.

PURPOSE

To compare the diagnostic performances and cost analysis of fpMRI and mpMRI in clinically significant prostate cancer (csPCA).

STUDY TYPE

Retrospective.

POPULATION

A total of 103 patients (63 had csPCA) with a mean age of 66.83 (± 7.22) years were included.

FIELD STRENGTH/SEQUENCE

A 1.5-T; T1- and T2-weighted turbo spin-echo imaging (T1WI and T2WI), echo-planar diffusion-weighted images, and dynamic contrast-enhanced T1W imaging.

ASSESSMENT

Three readers independently evaluated the fpMRI and mpMRI images in different sessions blinded to all patient information. Diagnostic performances of fpMRI and mpMRI were evaluated. Kappa coefficient (κ) was used to determine the interreader and intrareader agreement. A detailed cost analysis was performed for each protocol.

STATISTICAL TESTS

Receiver operating characteristics analysis, area under the curve (AUC), and κ test were used. Diagnostic performance parameters were also calculated.

RESULTS

Of the 63 malignant index lesions (csPCA), 53/63 of those (84.1%) originated from the peripheral zone and 10/63 lesions (15.9%) originated from the transition zone. The AUC values for fpMRI were 0.878 for reader 1, 0.937 for reader 2, and 0.855 for reader 3. For mpMRI, the AUC values were 0.893 for reader 1, 0.94 for reader 2, and 0.862 for reader 3. Inter and intrareader agreements were moderate to substantial (κ range, 0.5-0.79). The total cost per examination was calculated as €12.39 and €30.10 for fpMRI and mpMRI, respectively.

DATA CONCLUSIONS

Fast MRI protocol has similar diagnostic performance with mpMRI in detecting csPCA, and fpMRI can be considered an alternative protocol that could create a lower financial burden on health-care systems.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY STAGE: 6.

Cost-effectiveness analysis of short biparametric magnetic resonance imaging protocol in men at risk of prostate cancer

OBJECTIVES

To compare the cost-effectiveness of a short biparametric MRI (BP-MRI) with that of contrast-enhanced multiparametric MRI (MP-MRI) for the detection of prostate cancer in men with elevated prostatespecific antigen (PSA) levels.

MATERIALS AND METHODS

We compared two diagnostic procedures for detection of prostate cancer (Pca), BP-MRI and MP-MRI, in terms of quality-adjusted life years (QALY), incremental costeffectiveness ratio (ICER) and net monetary benefit (NMB) for a hypothetical cohort of 10,000 patients. We compared two scenarios in which different protocols would be used for the early diagnosis of prostate cancer in relation to PSA values. Scenario 1. BP-MRI/MP-MRI yearly if > 3.0 ng/ml, every 2 years otherwise; Scenario 2. BP-MRI/MP-MRI yearly with age-dependent threshold 3.5 ng/ml (50-59 years), 4.5 ng/ml (60-69 years), 6.5 ng/ml (70-79 years).

RESULTS

BP-MRI was more effective than the comparator in terms of cost (160.10 € vs 249.99€) QALYs (a mean of 9.12 vs 8.46), ICER (a mean of 232.45) and NMB (a mean of 273.439 vs 251.863). BP-MRI was dominant, being more effective and less expensive, with a lower social cost. Scenario 2 was more cost-effective compared to scenario 1.

CONCLUSIONS

Our results confirmed the hypothesis that a short bi-parametric MRI protocol represents a cost-efficient procedure, optimizing resources in a policy perspective.

Abbreviated MR Protocols in Prostate MRI

Prostate MRI is an integral part of the clinical work-up in biopsy-naïve patients with suspected prostate cancer, and its use has been increasing steadily over the last years. To further its general availability and the number of men benefitting from it and to reduce the costs associated with MR, several approaches have been developed to shorten examination times, e.g., by focusing on sequences that provide the most useful information, employing new technological achievements, or improving the workflow in the MR suite. This review highlights these approaches; discusses their implications, advantages, and disadvantages; and serves as a starting point whenever an abbreviated prostate MRI protocol is being considered for implementation in clinical routine.

MRI as a screening tool for prostate cancer: current evidence and future challenges

Purpose

Prostate cancer (PCa) screening, which relies on prostate-specific antigen (PSA) testing, is a contentious topic that received negative attention due to the low sensitivity and specificity of PSA to detect clinically significant PCa. In this context, due to the higher sensitivity and specificity of magnetic resonance imaging (MRI), several trials investigate the feasibility of “MRI-only” screening approaches, and question if PSA testing may be replaced within prostate cancer screening programs.

Methods

This narrative review discusses the current literature and the outlook on the potential of MRI-based PCa screening.

Results

Several prospective randomized population-based trials are ongoing. Preliminary study results appear to favor the “MRI-only” approach. However, MRI-based PCa screening programs face a variety of obstacles that have yet to be fully addressed. These include the increased cost of MRI, lack of broad availability, differences in MRI acquisition and interpretation protocols, and lack of long-term impact on cancer-specific mortality. Partly, these issues are being addressed by shorter and simpler MRI approaches (5–20 min bi-parametric MRI), novel quality indicators (PI-QUAL) and the implementation of radiomics (deep learning, machine learning).

Conclusion

Although promising preliminary results were reported, MRI-based PCa screening still lack long-term data on crucial endpoints such as the impact of MRI screening on mortality. Furthermore, the issues of availability, cost-effectiveness, and differences in MRI acquisition and interpretation still need to be addressed.

Diagnostic Accuracy of Abbreviated Bi-Parametric MRI (a-bpMRI) for Prostate Cancer Detection and Screening: A Multi-Reader Study

(1) Background: There is currently limited evidence on the diagnostic accuracy of abbreviated biparametric MRI (a-bpMRI) protocols for prostate cancer (PCa) detection and screening. In the present study, we aim to investigate the performance of a-bpMRI among multiple readers and its potential application to an imaging-based screening setting. (2) Methods: A total of 151 men who underwent 3T multiparametric MRI (mpMRI) of the prostate and transperineal template prostate mapping biopsies were retrospectively selected. Corresponding bpMRI (multiplanar T2WI, DWI, ADC maps) and a-bpMRI (axial T2WI and b 2000 s/mm² DWI only) dataset were derived from mpMRI. Three experienced radiologists scored a-bpMRI, standard biparametric MRI (bpMRI) and mpMRI in separate sessions. Diagnostic accuracy and interreader agreement of a-bpMRI was tested for different positivity thresholds and compared to bpMRI and mpMRI. Predictive values of a-bpMRI were computed for lower levels of PCa prevalence to simulate a screening setting. The primary definition of clinically significant PCa (csPCa) was Gleason ≥ 4 + 3, or cancer core length ≥ 6 mm. (3) Results: The median age was 62 years, the median PSA was 6.8 ng/mL, and the csPCa prevalence was 40%. Using a cut off of MRI score ≥ 3, the sensitivity and specificity of a-bpMRI were 92% and 48%, respectively. There was no significant difference in sensitivity compared to bpMRI and mpMRI. Interreader agreement of a-bpMRI was moderate (AC1 0.58). For a low prevalence of csPCa (e.g., <10%), higher cut offs (MRI score ≥ 4) yield a more favourable balance between the predictive values and positivity rate of MRI. (4) Conclusion: Abbreviated bpMRI protocols could match the diagnostic accuracy of bpMRI and mpMRI for the detection of csPCa. If a-bpMRI is used in low-prevalence settings, higher cut-offs for MRI positivity should be prioritised.

Preliminary results of abdominal simultaneous multi-slice accelerated diffusion-weighted imaging with motion-correction in patients with cystic fibrosis and impaired compliance

OBJECTIVES

The aim of this prospective study was to compare scan time, image quality, signal-to-noise Ratio (SNR), and apparent diffusion coefficient (ADC) values of simultaneous multi-slice accelerated diffusion-weighted imaging with motion-correction (DWI SMS Moco) to standard diffusion-weighted imaging (sDWI) in free-breathing abdominal magnetic resonance imaging (MRI) in pediatric and young adult patients with cystic fibrosis (CF).

MATERIAL AND METHODS

16 patients (7 male and 9 female, 12-41 years old) with CF were examined prospectively in a single-center from November 2020 to March 2021 on a 1.5 Tesla clinical MR scanner. The characteristics of overall image quality and delimitability of mesenteric lymph nodes were evaluated using a 5-point Likert scale by two experienced pediatric radiologists independently from each other. Quantitative parameters with SNR and ADC values were assessed in 8 different locations and compared using a Wilcoxon signed-rank test.

RESULTS

The acquisition time for DWI SMS Moco was 32% shorter than for sDWI. Regarding quality comparison, overall image quality and delimitability of mesenteric lymph nodes were significant higher in DWI SMS Moco (p ≤ 0.05 for both readers). The readers preferred DWI SMS Moco to sDWI in all cases (16/16). Mean SNR values from DWI SMS Moco and sDWI were similar in 7 from 8 locations. The ADC values showed no significant difference between DWI SMS Moco and sDWI in any of the evaluated locations (p > 0.05).

CONCLUSIONS

The DWI SMS Moco improves overall image quality and delimitability of mesenteric lymph nodes compared to sDWI with similar SNR and ADC values and a distinguished reduction of scan time in free-breathing by one third. We conclude that MRI with DWI SMS Moco could be helpful in monitoring the effect of the high-efficiency modulator (HEM) therapy in cystic fibrosis (CF) patients homozygous or heterozygous for F508del in the abdomen.

Accuracy of fractal analysis and PI-RADS assessment of prostate magnetic resonance imaging for prediction of cancer grade groups: a clinical validation study

Objectives

Multiparametric MRI with Prostate Imaging Reporting and Data System (PI-RADS) assessment is sensitive but not specific for detecting clinically significant prostate cancer. This study validates the diagnostic accuracy of the recently suggested fractal dimension (FD) of perfusion for detecting clinically significant cancer.

Materials and methods

Routine clinical MR imaging data, acquired at 3 T without an endorectal coil including dynamic contrast-enhanced sequences, of 72 prostate cancer foci in 64 patients were analyzed. In-bore MRI-guided biopsy with International Society of Urological Pathology (ISUP) grading served as reference standard. Previously established FD cutoffs for predicting tumor grade were compared to measurements of the apparent diffusion coefficient (25th percentile, ADC₂₅) and PI-RADS assessment with and without inclusion of the FD as separate criterion.

Results

Fractal analysis allowed prediction of ISUP grade groups 1 to 4 but not 5, with high agreement to the reference standard (κ_FD = 0.88 [CI: 0.79–0.98]). Integrating fractal analysis into PI-RADS allowed a strong improvement in specificity and overall accuracy while maintaining high sensitivity for significant cancer detection (ISUP > 1; PI-RADS alone: sensitivity = 96%, specificity = 20%, area under the receiver operating curve [AUC] = 0.65; versus PI-RADS with fractal analysis: sensitivity = 95%, specificity = 88%, AUC = 0.92, p < 0.001). ADC₂₅ only differentiated low-grade group 1 from pooled higher-grade groups 2–5 (κ_ADC = 0.36 [CI: 0.12–0.59]). Importantly, fractal analysis was significantly more reliable than ADC₂₅ in predicting non-significant and clinically significant cancer (AUC_FD = 0.96 versus AUC_ADC = 0.75, p < 0.001). Diagnostic accuracy was not significantly affected by zone location.

Conclusions

Fractal analysis is accurate in noninvasively predicting tumor grades in prostate cancer and adds independent information when implemented into PI-RADS assessment. This opens the opportunity to individually adjust biopsy priority and method in individual patients.

Key Points

• Fractal analysis of perfusion is accurate in noninvasively predicting tumor grades in prostate cancer using dynamic contrast-enhanced sequences (κ_FD = 0.88).

• Including the fractal dimension into PI-RADS as a separate criterion improved specificity (from 20 to 88%) and overall accuracy (AUC from 0.86 to 0.96) while maintaining high sensitivity (96% versus 95%) for predicting clinically significant cancer.

• Fractal analysis was significantly more reliable than ADC₂₅ in predicting clinically significant cancer (AUC_FD = 0.96 versus AUC_ADC = 0.75).

Clinical Evaluation of an Abbreviated Contrast-Enhanced Whole-Body MRI for Oncologic Follow-Up Imaging

Over the last decades, overall survival for most cancer types has increased due to earlier diagnosis and more effective treatments. Simultaneously, whole-body MRI-(WB-MRI) has gained importance as a radiation free staging alternative to computed tomography. The aim of this study was to evaluate the diagnostic confidence and reproducibility of a novel abbreviated 20-min WB-MRI for oncologic follow-up imaging in patients with melanoma. In total, 24 patients with melanoma were retrospectively included in this institutional review board-approved study. All patients underwent three consecutive staging examinations via WB-MRI in a clinical 3 T MR scanner with an abbreviated 20-min protocol. Three radiologists independently evaluated the images in a blinded, random order regarding image quality (overall image quality, organ-based image quality, sharpness, noise, and artifacts) and regarding its diagnostic confidence on a 5-point-Likert-Scale (5 = excellent). Inter-reader agreement and reproducibility were assessed. Overall image quality and diagnostic confidence were rated to be excellent (median 5, interquartile range [IQR] 5–5). The sharpness of anatomic structures, and the extent of noise and artifacts, as well as the assessment of lymph nodes, liver, bone, and the cutaneous system were rated to be excellent (median 5, IQR 4–5). The image quality of the lung was rated to be good (median 4, IQR 4–5). Therefore, our study demonstrated that the novel accelerated 20-min WB-MRI protocol is feasible, providing high image quality and diagnostic confidence with reliable reproducibility for oncologic follow-up imaging.

Fast T2-Weighted Imaging With Deep Learning-Based Reconstruction: Evaluation of Image Quality and Diagnostic Performance in Patients Undergoing Radical Prostatectomy

BACKGROUND

Deep learning-based reconstruction (DLR) can potentially improve image quality by reduction of noise, thereby enabling fast acquisition of magnetic resonance imaging (MRI). However, a systematic evaluation of image quality and diagnostic performance of MRI using short acquisition time with DLR has rarely been investigated in men with prostate cancer.

PURPOSE

To assess the image quality and diagnostic performance of MRI using short acquisition time with DLR for the evaluation of extraprostatic extension (EPE).

STUDY TYPE

Retrospective.

POPULATION

One hundred and nine men.

FIELD STRENGTH/SEQUENCE

3 T; turbo spin echo T2-weighted images (T2WI), echo-planar diffusion-weighted, and spoiled gradient echo dynamic contrast-enhanced images.

ASSESSMENT

To compare image quality, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) and subjective analysis using Likert scales on three T2WIs (MRI using conventional acquisition time, MRI using short acquisition time [fast MRI], and fast MRI with DLR) were performed. The diagnostic performance for EPE was evaluated by three independent readers.

STATISTICAL TESTS

SNR, CNR, and image quality scores across the three imaging protocols were compared using Friedman tests. The diagnostic performance for EPE was assessed using the area under receiver operating characteristic curves (AUCs). P < 0.05 was considered statistically significant.

RESULTS

Fast MRI with DLR demonstrated significantly higher SNR (mean ± SD, 14.7 ± 6.8 vs. 8.8 ± 4.9) and CNR (mean ± SD, 6.5 ± 6.3 vs. 3.4 ± 3.6) values and higher image quality scores (median, 4.0 vs. 3.0 for three readers) than fast MRI. The AUCs for EPE were significantly higher with the use of DLR (0.86 vs. 0.75 for reader 2 and 0.82 vs. 0.73 for reader 3) compared with fast MRI, whereas differences were not significant for reader 1 (0.81 vs. 0.74; P = 0.09).

DATA CONCLUSION

DLR may be useful in reducing the acquisition time of prostate MRI without compromising image quality or diagnostic performance.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 3.

1.5 vs 3 Tesla Magnetic Resonance Imaging: A Review of Favorite Clinical Applications for Both Field Strengths-Part 1

ABSTRACT

Whole-body magnetic resonance imaging (MRI) systems with a field strength of 3 T have been offered by all leading manufacturers for approximately 2 decades and are increasingly used in clinical diagnostics despite higher costs. Technologically, MRI systems operating at 3 T have reached a high standard in recent years, as well as the 1.5-T devices that have been in use for a longer time. For modern MRI systems with 3 T, more complexity is required, especially for the magnet and the radiofrequency (RF) system (with multichannel transmission). Many clinical applications benefit greatly from the higher field strength due to the higher signal yield (eg, imaging of the brain or extremities), but there are also applications where the disadvantages of 3 T might outweigh the advantages (eg, lung imaging or examinations in the presence of implants). This review describes some technical features of modern 1.5-T and 3-T whole-body MRI systems, and reports on the experience of using both types of devices in different clinical settings, with all sections written by specialist radiologists in the respective fields.This first part of the review includes an overview of the general physicotechnical aspects of both field strengths and elaborates the special conditions of diffusion imaging. Many relevant aspects in the application areas of musculoskeletal imaging, abdominal imaging, and prostate diagnostics are discussed.

A Novel Deep Learning Based Computer-Aided Diagnosis System Improves the Accuracy and Efficiency of Radiologists in Reading Biparametric Magnetic Resonance Images of the Prostate: Results of a Multireader, Multicase Study

OBJECTIVE

The aim of this study was to evaluate the effect of a deep learning based computer-aided diagnosis (DL-CAD) system on radiologists' interpretation accuracy and efficiency in reading biparametric prostate magnetic resonance imaging scans.

MATERIALS AND METHODS

We selected 100 consecutive prostate magnetic resonance imaging cases from a publicly available data set (PROSTATEx Challenge) with and without histopathologically confirmed prostate cancer. Seven board-certified radiologists were tasked to read each case twice in 2 reading blocks (with and without the assistance of a DL-CAD), with a separation between the 2 reading sessions of at least 2 weeks. Reading tasks were to localize and classify lesions according to Prostate Imaging Reporting and Data System (PI-RADS) v2.0 and to assign a radiologist's level of suspicion score (scale from 1-5 in 0.5 increments; 1, benign; 5, malignant). Ground truth was established by consensus readings of 3 experienced radiologists. The detection performance (receiver operating characteristic curves), variability (Fleiss κ), and average reading time without DL-CAD assistance were evaluated.

RESULTS

The average accuracy of radiologists in terms of area under the curve in detecting clinically significant cases (PI-RADS ≥4) was 0.84 (95% confidence interval [CI], 0.79-0.89), whereas the same using DL-CAD was 0.88 (95% CI, 0.83-0.94) with an improvement of 4.4% (95% CI, 1.1%-7.7%; P = 0.010). Interreader concordance (in terms of Fleiss κ) increased from 0.22 to 0.36 (P = 0.003). Accuracy of radiologists in detecting cases with PI-RADS ≥3 was improved by 2.9% (P = 0.10). The median reading time in the unaided/aided scenario was reduced by 21% from 103 to 81 seconds (P < 0.001).

CONCLUSIONS

Using a DL-CAD system increased the diagnostic accuracy in detecting highly suspicious prostate lesions and reduced both the interreader variability and the reading time.

Multi-band whole-body diffusion-weighted imaging with inversion recovery fat saturation: Effects of respiratory compensation

Purpose

To prospectively compare artefacts and image quality in testicular stage I cancer patients using different combinations of breathing schemes and Multi-band (MB) in whole-body DWIBS at 1.5 T.Diffusion-Weighted whole-body Imaging with Background body signal Suppression (DWIBS) using inversion recovery (IR) fat saturation is a cornerstone in oncologic whole-body MRI, but implementation is restrained by long acquisition times. The new Multi-Band (MB) technique reduces scan time which can be reinvested in respiratory compensation.

Methods

Thirty testicular cancer stage I patients were included. Three variations of whole-body DWIBS were tested: Standard free Breathing (FB)-DWIBS, FB-MB-DWIBS and Respiratory triggered (RT)-MB-DWIBS. Artefacts and image quality of b = 800 s/mm² images were evaluated using a Likert scale. No pathology was revealed. SNR was calculated in a healthy volunteer.

Results

RT-MB-DWIBS was rated significantly better than FB-DWIBS in the thorax (p < 0.001) and abdomen (p < 0.001), but not in the pelvis (p = 0.569). FB-MB-DWIBS was ranked significantly lower than both FB-DWIBS (p < 0.001) and RT-MB-DWIBS (p < 0.001) at all locations. However, FB-MB-DWIBS was scanned in half the time without being less than "satisfactory". Few artefacts were encountered. SNR was similar for low-intensity tissues, but the SNR in high-intensity and respiratory-prone tissue (spleen) was slightly lower for FB-DWIBS than the other sequences.

Conclusion

Images produced by the sequences were similar. MB enables the use of respiratory trigger or can be used to produce very fast free-breathing DWI with acceptable image quality.

Improving workflow in prostate MRI: AI-based decision-making on biparametric or multiparametric MRI

OBJECTIVES

To develop and validate an artificial intelligence algorithm to decide on the necessity of dynamic contrast-enhanced sequences (DCE) in prostate MRI.

METHODS

This study was approved by the institutional review board and requirement for study-specific informed consent was waived. A convolutional neural network (CNN) was developed on 300 prostate MRI examinations. Consensus of two expert readers on the necessity of DCE acted as reference standard. The CNN was validated in a separate cohort of 100 prostate MRI examinations from the same vendor and 31 examinations from a different vendor. Sensitivity/specificity were calculated using ROC curve analysis and results were compared to decisions made by a radiology technician.

RESULTS

The CNN reached a sensitivity of 94.4% and specificity of 68.8% (AUC: 0.88) for the necessity of DCE, correctly assigning 44%/34% of patients to a biparametric/multiparametric protocol. In 2% of all patients, the CNN incorrectly decided on omitting DCE. With a technician reaching a sensitivity of 63.9% and specificity of 89.1%, the use of the CNN would allow for an increase in sensitivity of 30.5%. The CNN achieved an AUC of 0.73 in a set of examinations from a different vendor.

CONCLUSIONS

The CNN would have correctly assigned 78% of patients to a biparametric or multiparametric protocol, with only 2% of all patients requiring re-examination to add DCE sequences. Integrating this CNN in clinical routine could render the requirement for on-table monitoring obsolete by performing contrast-enhanced MRI only when needed.

Abbreviated MR Protocols for Chronic Liver Disease and Liver Cancer

MR imaging has become a powerful tool for assessing liver disease and liver cancer; however, it entails complex, time-consuming, and costly protocols. Abbreviated MR imaging (AMRI) is emerging as a simpler, faster, and low-cost alternative to full-abdominal MR imaging protocols. Different AMRI approaches have been tested successfully in hepatocellular carcinoma detection and for assessment of diffuse liver disease. The most accurate, time-effective, and cost-effective protocol as well as the target population need to be defined. Prospective and multicentric studies, exploring different AMRI protocols versus the current standard of reference, should be performed.

Accuracy of abbreviated multiparametric MRI-derived protocols in predicting local staging of prostate cancer in men undergoing radical prostatectomy

BACKGROUND

Abbreviated magnetic resonance imaging (aMRI) protocols have emerged as an alternative to multiparametric MRI (mpMRI) to reduce examination time and costs.

PURPOSE

To compare multiple aMRI protocols for predicting pathological stage ≥T3 (≥pT3) prostate cancer (PCa).

MATERIAL AND METHODS

One hundred and eight men undergoing staging mpMRI before radical prostatectomy (RP) were retrospectively evaluated. 3.0-T imaging was performed with a 32-channel surface coil and a protocol including diffusion-weighted imaging (DWI), transverse T2-weighted (tT2W) imaging, coronal T2W (cT2W) imaging, sagittal T2W (sT2) imaging, and dynamic contrast-enhanced (DCE) imaging. Two readers independently assessed whether any MRI observation showed stage ≥T3 on each sequence (reading order: DWI, cT2W, tT2W, sT2W, DCE). Final stage was assessed by matching readers' assignments to pathology, and combining them into eight protocols: DWI + tT2W, DWI + cT2W + tT2W, DWI + tT2W + sT2W, DWI + cT2W + tT2W + sT2W, DWI + tT2W + DCE, DWI + cT2W + tT2W + DCE, DWI + tT2W + sT2W + DCE, and mpMRI. Diagnostic accuracy and inter-reader agreement for aMRI protocols were calculated.

RESULTS

Prevalence of ≥pT3 PCa was 31.5%. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of aMRI protocols were comparable to mpMRI for R1. Sensitivity was 74.3% (95% confidence interval [CI] 64.8-72.0) to 77.1% (95% CI 67.9-84.4), and NPV 86.8% (95% CI 78.6-92.3) to 88.1% (95% CI 80.1-93.3). All accuracy measures of the various aMRI protocols were similar to mpMRI also for R2, albeit all slightly lower compared to R1. On a per-protocol basis, there was substantial inter-reader agreement in predicting stage ≥pT3 (k 0.63-0.67).

CONCLUSION

When comparing the diagnostic accuracy of multiple aMRI protocols against mpMRI for predicting stage ≥pT3 PCa, the protocol with the fewest sequences (DWI + tT2W) is apparently equivalent to standard mpMRI.

Performance of an Automated Workflow for Magnetic Resonance Imaging of the Prostate: Comparison With a Manual Workflow

OBJECTIVES

The aim of this study was to evaluate the performance of an automated workflow for multiparametric magnetic resonance imaging (mpMRI) of the prostate compared with a manual mpMRI workflow.

MATERIALS AND METHODS

This retrospective study was approved by the local ethics committee. Two MR technicians scanned 2 healthy volunteers with a prototypical highly automated workflow (Siemens Healthineers GmbH, Erlangen, Germany) and with a manually adjusted scan protocol each. Thirty patients (mean age ± standard deviation, 68 ± 11 years; range, 41-93 years) with suspected prostate cancer underwent mpMRI on a 3 T MRI scanner. Fifteen patients were examined with the automated workflow and 15 patients with a conventional manual workflow. Two readers assessed image quality (contrast, zone distinction, organ margins, seminal vesicles, lymph nodes), organ coverage, orientation (T2w sequences), and artifacts (motion, susceptibility, noise) on a 5-point scale (1, poor; 5, excellent). Examination time and MR technicians' acceptance were compared between both groups. Interreader agreement was evaluated with Cohen's kappa (κ).

RESULTS

The automated workflow proved consistent for sequence orientation and image quality in the intraindividual comparisons. There were no significant differences in examination time (automated vs manual; median 26 vs 28 minutes; interquartile range [IQR], 25-28 minutes each; P = 0.57), study volume coverage, artifacts, or scores for T2w sequence orientation (5 vs 4 each; P > 0.3). Overall image quality was superior for automated MRI (4.6 vs 3.8; IQR, 3.9-4.8 vs 3.2-4.3; P = 0.002), especially concerning organ delineation and seminal vesicles (P = 0.045 and P = 0.013). The acceptance score was higher for the manual workflow (median, 10 vs 8; IQR, 10 vs 7-10; P = 0.002). General interreader agreement was excellent (κ = 0.832; P < 0.001).

CONCLUSIONS

The automated workflow for prostate MRI ensures accurate sequence orientation and maintains high image quality, whereas examination time remained unaffected compared with the manual procedure in our institution.

Impact of different phased-array coils on the quality of prostate magnetic resonance images

•

Image quality is similar for different body phased-array receive coil setups.

•

An 18-channel body phased-array receive coil setup achieved good image quality.

•

60-channel body phased-array receive coil setup slightly improves SNR in T2W images.

Purpose

To evaluate the influence of body phased-array (BPA) receive coil setups on signal-to-noise ratio (SNR) and image quality (IQ) in prostate MRI.

Methods

This prospective study evaluated axial T2-weighted images (T2W-TSE) and DWI of the prostate in ten healthy volunteers with 18-channel (18CH), 30-channel and 60-channel (60CH) BPA receive coil setups. SNR and ADC values were assessed in the peripheral and transition zones (TZ). Two radiologists rated IQ features. Differences in qualitative and quantitative image features between BPA receive coil setups were compared. After correction for multiple comparisons, p-values <0.004 for quantitative and p-values <0.017 for qualitative image analysis were considered statistically significant.

Results

Significantly higher SNR was found in T2W-TSE images in the TZ using 60CH BPA compared to 18CH BPA coil setups (15.20 ± 4.22 vs. 7.68 ± 2.37; p = 0.001). There were no significant differences between all other quantitative (T2W-TSE, p = 0.007−0.308; DWI, p = 0.024−0.574) and qualitative image features (T2W-TSE, p = 0.083–1.0; DWI, p = 0.046–1.0).

Conclusion

60CH BPA receive coil setup showed marginal SNR improvement in T2W-TSE images. Good IQ could be achieved with 18CH BPA coil setups.

Autonomous Detection and Classification of PI-RADS Lesions in an MRI Screening Population Incorporating Multicenter-Labeled Deep Learning and Biparametric Imaging: Proof of Concept

Background: Opportunistic prostate cancer (PCa) screening is a controversial topic. Magnetic resonance imaging (MRI) has proven to detect prostate cancer with a high sensitivity and specificity, leading to the idea to perform an image-guided prostate cancer (PCa) screening; Methods: We evaluated a prospectively enrolled cohort of 49 healthy men participating in a dedicated image-guided PCa screening trial employing a biparametric MRI (bpMRI) protocol consisting of T2-weighted (T2w) and diffusion weighted imaging (DWI) sequences. Datasets were analyzed both by human readers and by a fully automated artificial intelligence (AI) software using deep learning (DL). Agreement between the algorithm and the reports—serving as the ground truth—was compared on a per-case and per-lesion level using metrics of diagnostic accuracy and k statistics; Results: The DL method yielded an 87% sensitivity (33/38) and 50% specificity (5/10) with a k of 0.42. 12/28 (43%) Prostate Imaging Reporting and Data System (PI-RADS) 3, 16/22 (73%) PI-RADS 4, and 5/5 (100%) PI-RADS 5 lesions were detected compared to the ground truth. Targeted biopsy revealed PCa in six participants, all correctly diagnosed by both the human readers and AI. Conclusions: The results of our study show that in our AI-assisted, image-guided prostate cancer screening the software solution was able to identify highly suspicious lesions and has the potential to effectively guide the targeted-biopsy workflow.

How Fast Can We Go: Abbreviated Prostate MR Protocols

PURPOSE OF REVIEW

Multiparametric MRI (mpMRI), composed of T2WI, DWI, and DCE sequences, is effective in identifying prostate cancer (PCa), but length and cost preclude its application as a PCa screening tool. Here we review abbreviated MRI protocols that shorten or omit conventional mpMRI components to reduce scan time and expense without forgoing diagnostic accuracy.

RECENT FINDINGS

The DCE sequence, which plays a limited diagnostic role in PI-RADS, is eliminated in variations of the biparametric MRI (bpMRI). T2WI, the lengthiest sequence, is truncated by only acquiring the axial plane or utilizing 3D acquisition with subsequent 2D reconstruction. DW-EPI_SMS further accelerates DWI acquisition. The fastest protocol described to date consists of just DW-EPI_SMS and axial-only 2D T2WI and runs less than 5 min. Abbreviated protocols can mitigate scan expense and increase scan access, allowing prostate MRI to become an efficient PCa screening tool.

Prostate cancer local staging using biparametric MRI: assessment and comparison with multiparametric MRI

PURPOSE

The value of adding dynamic contrast-enhanced (DCE) imaging to T2-weighted (T2W) magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) to improve the detection and staging of prostate cancer (PCa) is unclear. The aim of this retrospective study was to compare the diagnostic performance of non-contrast biparametric MRI (bpMRI) with multiparametric MRI (mpMRI), for local staging of PCa.

METHODS

Ninety-two patients who underwent prostate MRI on a 3-Tesla MRI system before radical prostatectomy for PCa were included retrospectively. Four readers independently assigned a Likert score (ranging from 1 to 5) for predicting extra-prostatic extension (EPE) on T2W + DWI (bpMRI) and then on T2W + DWI + DCE imaging (mpMRI). MRI-based staging results were compared with radical prostatectomy histology. A prediction of EPE generalized linear mixed model was used to assess the added-value of DCE and discriminative power of staging accuracy by area under the receiver-operating curve (AUC ROC).

RESULTS

AUC was not significantly improved by DCE (mpMRI, AUC = 0.73 [95%CI: 0.655‒0.827] vs. bpMRI, AUC = 0.76 [95%CI: 0.681‒0.846]). After applying a selection procedure, only MRI criteria were retained in a multivariate model. The following criteria were significantly associated with local extension: localization in the peripheral zone (p < 0.001), maximal diameter of the lesion (<0.0001), curvilinear capsular contact on T2W (p < 0.0001), capsular irregularity on T2W (p < 0.0001), bulging on T2W (p < 0.001) and seminal vesicle hypo-signal (p < 0.001).

CONCLUSION

Use of bpMRI did not result in a decrease in local staging accuracy.

Comparison of multiple abbreviated multiparametric MRI-derived protocols for the detection of clinically significant prostate cancer

BACKGROUND

The aim of this paper was to compare the accuracy of multiple abbreviated multiparametric magnetic resonance imaging (mpMRI)-derived protocols in detecting clinically significant prostate cancer (csPCa).

METHODS

One hundred and eight men undergoing staging 3.0T mpMRI with a Prostate Imaging - Reporting and Data System version 2 (PI-RADSv2)-compliant protocol before radical prostatectomy (RP) were retrospectively evaluated. Two readers (R1, R2) independently analyzed mpMRI, assigning a PI-RADSv2 category to each observation as appearing on each examination sequence. A study coordinator assessed final PI-RADSv2 category by combining readers' assignments according to four protocols: short MRI (sMRI) (diffusion-weighted imaging + axial T2-weighted imaging), contrast-enhanced short MRI (cesMRI) (sMRI + dynamic contrast-enhanced [DCE] imaging), biparametric MRI (diffusion-weighted imaging + multiplanar T2-weigthed imaging), and mpMRI. Using RP pathology as the reference standard for csPCa, we calculated the per-lesion cancer detection rate (CDR) and false discovery rate (FDR) for each MRI protocol (cut-off PI-RADSv2 category ≥3), and the per-PI-RADSv2 category prevalence of csPCa and false positives.

RESULTS

Pathology after RP found 142 csPCas with median International Society of Urogenital Pathology grade group 2, and stage ≤pT2c in 68.6% of cases. CDR was comparable across the four MRI protocols (74.6% to 75.3% for R1, and 68.3% for R2). FDR was comparable as well (14.4%-14.5% for R1 and 11.1% for R2). sMRI was the minimum protocol equaling mpMRI in terms of CDR, although cesMRI, similarly to mpMRI, was associated with fewer PI-RADSv2 category 3 assignments and higher prevalence of csPCa within PI-RADSv2 category 3 observations (66.7% versus 76.9% for R1, and 100% versus 91.7% for R2, respectively).

CONCLUSIONS

Among multiple abbreviated mpMRI-derived protocols, cesMRI was the one equaling mpMRI in terms of csPCa detection and minimizing PI-RADSv2 category 3 assignments.

Comparison of the PI-RADS 2.1 scoring system to PI-RADS 2.0: Impact on diagnostic accuracy and inter-reader agreement

Purpose

To assess the value of the PI-RADS 2.1 scoring system in the detection of prostate cancer on multiparametric MRI in comparison to the standard PI-RADS 2.0 system and to assess its inter-reader variability.

Materials and methods

This IRB-approved study included 229 patients undergoing multiparametric prostate MRI prior to MRI-guided TRUS-based biopsy, which were retrospectively recruited from our prospectively maintained institutional database. Two readers with high (reader 1, 6 years) and low (reader 2, 2 years) level of expertise identified the lesion with the highest PI-RADS score for both version 2.0 and 2.1 for each patient. Inter-reader agreement was estimated, and diagnostic accuracy analysis was performed.

Results

Inter-reader agreement on PI-RADS scores was fair for both version 2.0 (kappa: 0.57) and 2.1 (kappa: 0.51). Detection rates for prostate cancer (PCa) and clinically significant prostate cancer (csPCa) were almost identical for both PI-RADS versions and higher for the more experienced reader (AUC, Reader 1: PCa, 0.881–0.887, csPCa, 0.874–0.879; Reader 2: PCa, 0.765, csPCa, 0.746–0.747; both p > 0.05), both when using a PI-RADS score of ≥ 4 and ≥3 as indicators for positivity for cancer.

Conclusions

The new PI-RADS 2.1 scoring system showed comparable diagnostic performance and inter-reader variability compared to version 2.0. The introduced changes in the version 2.1 seem only to take effect in a very small number of patients.

The Role of Imaging in Bladder Cancer Diagnosis and Staging

Bladder cancer (BC) is the most common cancer of the urinary tract in the United States. Imaging plays a significant role in the management of patients with BC, including the locoregional staging and evaluation for distant metastatic disease, which cannot be assessed at the time of cystoscopy and biopsy/resection. We aim to review the current role of cross-sectional and molecular imaging modalities for the staging and restaging of BC and the potential advantages and limitations of each imaging modality. CT is the most widely available and frequently utilized imaging modality for BC and demonstrates good performance for the detection of nodal and visceral metastatic disease. MRI offers potential value for the locoregional staging and evaluation of muscular invasion of BC, which is critically important for prognostication and treatment decision-making. FDG-PET/MRI is a novel hybrid imaging modality combining the advantages of both MRI and FDG-PET/CT in a single-setting comprehensive staging examination and may represent the future of BC imaging evaluation.

Rethinking prostate cancer screening: could MRI be an alternative screening test?

In the past decade rigorous debate has taken place about population-based screening for prostate cancer. Although screening by serum PSA levels can reduce prostate cancer-specific mortality, it is unclear whether the benefits outweigh the risks of false-positive results and overdiagnosis of insignificant prostate cancer, and it is not recommended for population-based screening. MRI screening for prostate cancer has the potential to be analogous to mammography for breast cancer or low-dose CT for lung cancer. A number of potential barriers and technical challenges need to be overcome in order to implement such a programme. We discuss different approaches to MRI screening that could address these challenges, including abbreviated MRI protocols, targeted MRI screening, longer rescreening intervals and a multi-modal screening pathway. These approaches need further investigation, and we propose a phased stepwise research framework to ensure proper evaluation of the use of a fast MRI examination as a screening test for prostate cancer.

Comparison of Biparametric and Multiparametric MRI for Clinically Significant Prostate Cancer Detection With PI-RADS Version 2.1

BACKGROUND

Biparametric MRI (bpMRI) without dynamic contrast-enhanced MRI (DCE-MRI) results in an elimination of adverse events, shortened examination time, and reduced costs, compared to multiparametric MRI (mpMRI). The ability of bpMRI to detect clinically significant prostate cancer (csPC) with the Prostate Imaging and Reporting Data System version 2.1 (PI-RADS v2.1) compared to standard mpMRI has not been studied extensively.

PURPOSE

To compare the interobserver reliability and diagnostic performance for detecting csPC of bpMRI and mpMRI using PI-RADS v2.1.

STUDY TYPE

Retrospective.

POPULATION

In all, 103 patients with elevated prostate-specific antigen (PSA) levels who underwent mpMRI and subsequent MRI-ultrasonography fusion-guided prostate-targeted biopsy (MRGB) with or without prostatectomy.

FIELD STRENGTH/SEQUENCES

T₂ -weighted imaging (T₂ WI), diffusion-weighted imaging (DWI), and DCE-MRI at 3T.

ASSESSMENT

Three readers independently assessed each suspected PC lesion, assigning a score of 1-5 for T₂ WI, a score of 1-5 for DWI, and positive and negative for DCE-MRI according to PI-RADS v2.1 and determined the overall PI-RADS assessment category of bpMRI (T₂ WI and DWI) and mpMRI (T₂ WI, DWI, and DCE-MRI). The reference standard was MRGB or prostatectomy-derived histopathology.

STATISTICAL TESTING

Statistical analysis was performed using the kappa statistic and McNemar and Delong tests.

RESULTS

Of the 165 suspected PC lesions in 103 patients, 81 were diagnosed with csPC and 84 with benign conditions. Interobserver variability of PI-RADS assessment category showed good agreement for bpMRI (kappa value = 0.642) and mpMRI (kappa value = 0.644). For three readers, the diagnostic sensitivity was significantly higher for mpMRI than for bpMRI (P < 0.001 to P = 0.016, respectively), whereas diagnostic specificity was significantly higher for bpMRI than for mpMRI (P < 0.001 each). For three readers, the area under the receiver operating characteristic curve (AUC) was higher for bpMRI than for mpMRI; however, the difference was significant only for Reader 1 and Reader 3 (Reader 1: 0.823 vs. 0.785, P = 0.035; Reader 2: 0.852 vs. 0.829, P = 0.099; and Reader 3: 0.828 vs. 0.773, P = 0.002).

DATA CONCLUSION

For detecting csPC using PI-RADS v2.1, the interobserver reliability and diagnostic performance of bpMRI was comparable with those of mpMRI.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY STAGE: 2.

Improved Liver Diffusion-Weighted Imaging at 3 T Using Respiratory Triggering in Combination With Simultaneous Multislice Acceleration

OBJECTIVES

The aim of this study was to retrospectively compare optimized respiratory-triggered diffusion-weighted imaging with simultaneous multislice acceleration (SMS-RT-DWI) of the liver with a standard free-breathing echo-planar DWI (s-DWI) protocol at 3 T with respect to the imaging artifacts inherent to DWI.

MATERIALS AND METHODS

Fifty-two patients who underwent a magnetic resonance imaging study of the liver were included in this retrospective study. Examinations were performed on a 3 T whole-body magnetic resonance system (MAGNETOM Skyra; Siemens Healthcare, Erlangen, Germany). In all patients, both s-DWI and SMS-RT-DWI of the liver were obtained. Images were qualitatively evaluated by 2 independent radiologists with regard to overall image quality, liver edge sharpness, sequence-related artifacts, and overall scan preference. For quantitative evaluation, signal-to-noise ratio was measured from signal-to-noise ratio maps. The mean apparent diffusion coefficient (ADC) was measured in each liver quadrant. The Wilcoxon rank-sum test was used for analysis of the qualitative parameters and the paired Student t test for quantitative parameters.

RESULTS

Overall image quality, liver edge sharpness, and sequence-related artifacts of SMS-RT-DWI received significantly better ratings compared with s-DWI (P < 0.05 for all). For 90.4% of the examinations, both readers overall preferred SMS-RT-DWI to s-DWI. Acquisition time for SMS-RT-DWI was 34% faster than s-DWI. Signal-to-noise ratio values were significantly higher for s-DWI at b50 but did not statistically differ at b800, and they were more homogenous for SMS-RT-DWI, with a significantly lower standard deviation at b50. Mean ADC values decreased from the left to right hepatic lobe as well as from cranial to caudal for s-DWI. With SMS-RT-DWI, mean ADC values were homogeneous throughout the liver.

CONCLUSIONS

Optimized, multislice, respiratory-triggered DWI of the liver at 3 T substantially improves image quality with a reduced scan acquisition time compared with s-DWI.

Abbreviated MRI Protocols for the Abdomen

Technical advances in MRI have improved image quality and have led to expanding clinical indications for its use. However, long examination and interpretation times, as well as higher costs, still represent barriers to use of MRI. Abbreviated MRI protocols have emerged as an alternative to standard MRI protocols. These abbreviated MRI protocols seek to reduce longer MRI protocols by eliminating unnecessary or redundant sequences that negatively affect cost, MRI table time, patient comfort, image quality, and image interpretation time. However, the diagnostic information is generally not compromised. Abbreviated MRI protocols have already been used successfully for hepatocellular carcinoma screening, for prostate cancer detection, and for screening for nonalcoholic fatty liver disease as well as monitoring patients with this disease. It has been reported that image acquisition time and costs can be considerably reduced with abbreviated MRI protocols, compared with standard MRI protocols, while maintaining a similar sensitivity and accuracy. Nevertheless, multiple applications still need to be explored in the abdomen and pelvis (eg, surveillance of metastases to the liver; follow-up of cystic pancreatic lesions, adrenal incidentalomas, and small renal masses; evaluation of ovarian cysts in postmenopausal women; staging of cervical and uterine corpus neoplasms; evaluation of müllerian duct anomalies). This article describes some successful applications of abbreviated MRI protocols, demonstrates how they can help in improving the MRI workflow, and explores potential future directions. ^©RSNA, 2019.

Evolution of prostate MRI: from multiparametric standard to less-is-better and different-is better strategies

Multiparametric magnetic resonance imaging (mpMRI) has become the standard of care to achieve accurate and reproducible diagnosis of prostate cancer. However, mpMRI is quite demanding in terms of technical rigour, patient's tolerability and safety, expertise in interpretation, and costs. This paper reviews the main technical strategies proposed as less-is-better solutions for clinical practice (non-contrast biparametric MRI, reduction of acquisition time, abbreviated protocols, computer-aided diagnosis systems), discussing them in the light of the available evidence and of the concurrent evolution of Prostate Imaging Reporting and Data System (PI-RADS). We also summarised research results on those advanced techniques representing an alternative different-is-better line of the still ongoing evolution of prostate MRI (quantitative diffusion-weighted imaging, quantitative dynamic contrast enhancement, intravoxel incoherent motion, diffusion tensor imaging, diffusional kurtosis imaging, restriction spectrum imaging, radiomics analysis, hybrid positron emission tomography/MRI).

Diagnostic Accuracy of a Rapid Biparametric MRI Protocol for Detection of Histologically Proven Prostate Cancer

OBJECTIVE

To evaluate the performance of a rapid, low cost, noncontrast MRI examination as a secondary screening tool in detection of clinically significant prostate cancer.

METHODS

In this prospective single institution study, 129 patients with elevated prostate-specific antigen levels or abnormal digital rectal examination findings underwent MRI with an abbreviated biparamatric MRI protocol consisting of high-resolution axial T2- and diffusion-weighted images. Index lesions were classified according to modified Prostate Imaging - Reporting and Data System (mPI-RADS) version 2.0. All patients underwent standard transrectal ultrasound-guided biopsy after MRI with the urologist being blinded to MRI results. Subsequently, all patients with suspicious lesions (mPI-RADS 3, 4, or 5) underwent cognitively guided targeted biopsy after discussion of MRI results with the urologist. Sensitivity and negative predictive value for identification of clinically significant prostate cancer (Gleason score 3+4 and above) were determined.

RESULTS

Rapid biparametric MRI discovered 176 lesions identified in 129 patients. Rapid MRI detected clinically significant cancers with a sensitivity of 95.1% with a negative predictive value of 95.1% and positive predictive value of 53.2%, leading to a change in management in 10.8% of the patients. False negative rate of biparametric (bp) MRI was 4.7%.

CONCLUSION

We found that a bp-MRI examination can detect clinically significant lesions and changed patient management in 10.8% of the patients. A rapid MRI protocol can be used as a useful secondary screening tool in men presenting with suspicion of prostate cancer.