First experiences and results after cryoablation of prostate cancer with histopathological evaluation and imaging-based follow-up

Aim: To share our experience after 28 cryoablation treatments for prostate cancer (PCa) with histopathology, clinical data and MRI as the follow-up methods. Methods: Clinical follow-up comprised prostate specific antigen (PSA)-measurements, PSA-density and quality-of-life-parameters. multi-parametric (mp)MRI pre- and post-cryoablation were retrospectively re-analyzed in 23 cases using Likert scores. Follow-up-histopathology was performed via MRI/ultrasound fusion-guided and/or systematic biopsy. Receiver operating characteristic curve analysis was performed. Results: 17 PCa (61%) were diagnosed within 12-month post-cryotherapy (infield and out-of-field disease). PSA levels and PSA density were not significantly different between patients with or without PCa recurrence. mpMRI can characterize the decrease in prostate volume and necrosis. Area under the curve for the detection of PCa was 81% (global Likert scores), 74-87% (T2), 78% (diffusion weighted imaging) and 57-78% (dynamic contrast enhanced imaging; Youden-selected cutoff ≥3). Conclusion: Besides histopathological evaluation and control biopsy, MRI might have the potential to accurately detect PCa after cryotherapy. Clinical data and interdisciplinary communication are required for efficient monitoring after cryoablation treatments for PCa.

Applicability of readout-segmented echoplanar diffusion weighted imaging for prostate MRI

To evaluate readout-segmented echoplanar (rsEPI) diffusion weighted imaging (DWI) for multiparametric (mp) magnetic resonance imaging (MRI) of the prostate compared to the established single-shot echoplanar imaging (ssEPI) sequence.One hundred ten consecutive patients with clinical suspicion of prostate cancer underwent mp prostate MRI using both, the ssEPI and the rsEPI DWI sequence. For an objective assessment, delineation of the prostate shape on both DWI sequences was compared to T2-weighted images by measuring organ diameters. Apparent diffusion coefficient (ADC) values, image contrast and contrast-to-noise ratio (CNR) were compared between the 2 sequences on a region-of-interest-based analysis. Diagnostic accuracy for quantitative ADC-values was calculated. Histopathology from MRI/ultrasound fusion-guided biopsy was used as reference standard. For a subjective assessment, 2 independent readers visually assessed image quality of both sequences using Likert-scales.Delineation of the prostate shape was more accurate with rsEPI compared to ssEPI. ADC values in target lesions were not significantly different but significantly higher in the surrounding normal prostatic tissue of the transition zone. CNR was comparable between ssEPI and rsEPI. Sensitivity and specificity were good for both sequences with 84/84% and 82/73% with a Youden selected cut-off of ADC = 0.971*10 mm/s for rsEPI and 1.017*10 mm/s for ssEPI. Anatomic artifacts were significantly less and SNR was lower on rsEPI compared to ssEPI in the subjective analysis.Delineation of the prostate shape was more accurate with rsEPI DWI than with ssEPI DWI with less anatomic artifacts and higher subjective SNR and image quality on rsEPI DW images. Diagnostic ability of quantitative ADC-values was not significantly different between the 2 sequences. Thus, rsEPI DWI might be more suitable for prostate MRI with regard to MRI-guided targeted biopsy and therapy planning.

Breast cancer risk in BRCA1/2 mutation carriers and noncarriers under prospective intensified surveillance

Comparably little is known about breast cancer (BC) risks in women from families tested negative for BRCA1/2 mutations despite an indicative family history, as opposed to BRCA1/2 mutation carriers. We determined the age-dependent risks of first and contralateral breast cancer (FBC, CBC) both in noncarriers and carriers of BRCA1/2 mutations, who participated in an intensified breast imaging surveillance program. The study was conducted between January 1, 2005, and September 30, 2017, at 12 university centers of the German Consortium for Hereditary Breast and Ovarian Cancer. Two cohorts were prospectively followed up for incident FBC (n = 4,380; 16,398 person-years [PY], median baseline age: 39 years) and CBC (n = 2,993; 10,090 PY, median baseline age: 42 years). Cumulative FBC risk at age 60 was 61.8% (95% CI 52.8-70.9%) for BRCA1 mutation carriers, 43.2% (95% CI 32.1-56.3%) for BRCA2 mutation carriers and 15.7% (95% CI 11.9-20.4%) for noncarriers. FBC risks were significantly higher than in the general population, with incidence rate ratios of 23.9 (95% CI 18.9-29.8) for BRCA1 mutation carriers, 13.5 (95% CI 9.2-19.1) for BRCA2 mutation carriers and 4.9 (95% CI 3.8-6.3) for BRCA1/2 noncarriers. Cumulative CBC risk 10 years after FBC was 25.1% (95% CI 19.6-31.9%) for BRCA1 mutation carriers, 6.6% (95% CI 3.4-12.5%) for BRCA2 mutation carriers and 3.6% (95% CI 2.2-5.7%) for noncarriers. CBC risk in noncarriers was similar to women with unilateral BC from the general population. Further studies are needed to confirm whether less intensified surveillance is justified in women from BRCA1/2 negative families with elevated risk.

Subclonal analysis in a lobular breast cancer with classical and solid growth pattern mimicking a solid-papillary carcinoma

Recently, a new variant of invasive lobular breast cancer (ILBC) with solid-papillary-like growth pattern has been described. We present a case of ILBC with solid-papillary-like growth pattern in the main tumour mass and classical invasive lobular growth pattern in adjacent satellite foci. The two tumour components were subjected to comprehensive molecular analyses. Both components were ER/PR-positive, HER2-negative, and showed a complete loss of E-cadherin and beta-catenin protein expression, as determined by immunohistochemistry. Gene expression profiling classified the main tumour and a satellite focus as luminal-B and luminal-A subtypes, respectively. Whole-genome copy number profiles were highly similar in both tumour components. Shared copy number alterations (CNAs) included gains of chromosome 1q21.1-q43 and losses of chromosome 16q11.2-q24.3, the locus of the CDH1/E-cadherin tumour suppressor gene. CNAs detected only in the main tumour included a gain of chromosome 20q12-q13.33 and a loss of chromosome 1p36.33-p34.3, which has recently been associated with the solid variant of ILBC. Next generation sequencing revealed an identical, truncating CDH1 mutation (p.G169fs*5) in both tumour components confirming a common clonal ancestry. In conclusion, we confirm the recently described variant of ILBC with solid-papillary-like growth pattern and provide evidence that it evolves from classical ILBC by subclonal evolution.

Standardized Reporting of Prostate MRI: Comparison of the Prostate Imaging Reporting and Data System (PI-RADS) Version 1 and Version 2

Introduction

Objective of our study was to determine the agreement between version 1 (v1) and v2 of the Prostate Imaging Reporting and Data System (PI-RADS) for evaluation of multiparametric prostate MRI (mpMRI) and to compare their diagnostic accuracy, their inter-observer agreement and practicability.

Material and Methods

mpMRI including T2-weighted imaging, diffusion-weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCE) of 54 consecutive patients, who subsequently underwent MRI-guided in-bore biopsy were re-analyzed according to PI-RADS v1 and v2 by two independent readers. Diagnostic accuracy for detection of prostate cancer (PCa) was assessed using ROC-curve analysis. Agreement between PI-RADS versions and observers was calculated and the time needed for scoring was determined.

Results

MRI-guided biopsy revealed PCa in 31 patients. Diagnostic accuracy for detection of PCa was equivalent with both PI-RADS versions for reader 1 with sensitivities and specificities of 84%/91% (AUC = 0.91 95%CI[0.8–1]) for PI-RADS v1 and 100%/74% (AUC = 0.92 95% CI[0.8–1]) for PI-RADS v2. Reader 2 achieved similar diagnostic accuracy with sensitivity and specificity of 74%/91% (AUC = 0.88 95%CI[0.8–1]) for PI-RADS v1 and 81%/91% (AUC = 0.91 95%CI[0.8–1]) for PI-RADS v2. Agreement between scores determined with different PI-RADS versions was good (reader 1: κ = 0.62, reader 2: κ = 0.64). Inter-observer agreement was moderate with PI-RADS v2 (κ = 0.56) and fair with v1 (κ = 0.39). The time required for building the PI-RADS score was significantly lower with PI-RADS v2 compared to v1 (24.7±2.3 s vs. 41.9±2.6 s, p<0.001).

Conclusion

Agreement between PI-RADS versions was high and both versions revealed high diagnostic accuracy for detection of PCa. Due to better inter-observer agreement for malignant lesions and less time demand, the new PI-RADS version could be more practicable for clinical routine.

Clear-cell variant urothelial carcinoma of the bladder: a case report and review of the literature

Clear cell variants of transitional cell carcinomas (TCC) of the bladder are extremely rare tumors. Only 6 cases have been reported until now. We report of a 67 year old man who presented with fast growing tumor disease. While initial diagnosis showed localized bladder tumor, final histopathology revealed pT4, G3, L1 urothelial carcinoma with clear cell differentiation. No more than 14 weeks after initial diagnosis the patient died from multi-organ failure after unsuccessful salvage laparotomy which showed massive tumor burden within the pelvis and peritoneal carcinosis. This case demonstrated an extremely fast tumor growth. Therefore, patients with clear cell urothelial carcinoma should be treated vigorously and without time delay. We present a case of clear cell variant of TCC which exhibited an extremely aggressive behavior. To our knowledge this is the fifth report of this rare disease.

Pulmonary valve replacement in chronic pulmonary regurgitation in adults with congenital heart disease: impact of preoperative QRS-duration and NT-proBNP levels on postoperative right ventricular function

BACKGROUND

Chronic severe pulmonary regurgitation (PR) causes progressive right ventricular (RV) dysfunction and heart failure. Parameters defining the optimal time point for surgery of chronic PR are lacking. The present study prospectively evaluated the impact of preoperative clinical parameters, cardiorespiratory function, QRS duration and NT-proBNP levels on post operative RV function and volumes assessed by cardiac magnetic resonance imaging (CMR) in patients with chronic severe PR undergoing pulmonary valve replacement.

METHODS AND RESULTS

CMR was performed pre- and 6 months postoperatively in 27 patients (23.6 ± 2.9 years, 15 women) with severe PR. Postoperatively, RV endsystolic (RVESVI) and enddiastolic volume indices (RVEDVI) decreased significantly (RVESVI pre 78.2 ± 20.4 ml/m² BSA vs. RVESVI post 52.2 ± 16.8 ml/m²BSA, p<0.001; RVEDVI pre 150.7 ± 27.7 ml/m²BSA vs. RVEDVI post 105.7 ± 26.7 ml/m²BSA; p<0,001). With increasing preoperative QRS-duration, postoperative RVEF decreased significantly (r=-0.57; p<0.005). Preoperative QRS-duration smaller than the median (156 ms) predicted an improved RVEF compared to QRS-duration≥ 156 ms (54.9% vs 46.8%, p<0.05). Multivariate analysis identified preoperative QRS duration as an independent predictor of postoperative RVEF (p<0.005). NT-proBNP levels correlated with changes in RVEDI (r=0.58 p<0,005) and RVESVI (r=0.63; p<0,0001). Multivariate analysis identified NT-proBNP levels prior to PVR as an independent predictor of volume changes (p<0.05).

CONCLUSION

Valve replacement in severe pulmonary regurgitation causes significant reduction of RV volumes. Both, preoperative NT-proBNP level elevation and QRS prolongation indicate patients with poorer outcome regarding RV function and volumes.

Accidental transplantation of a kidney with a cystic renal cell carcinoma following living donation: management and 1 yr follow-up

Transmission of cancer is a fatal risk in organ transplantation. We present a case of incidental renal carcinoma in a kidney obtained from a living donor. A 56-yr-old father was evaluated for donation for his 28-yr-old daughter. An MRT scan revealed two cysts in the right kidney. Right-sided donor nephrectomy and subsequent transplantation was performed. The wall of the prominent cyst was partially excised prior to transplantation. Histology revealed a high-grade renal clear cell carcinoma 10 d after transplantation. Following careful evaluation the recipient underwent partial nephrectomy. Immunosuppression was switched to rapamune. The graft function remained stable. Donor and recipient are without evidence of tumor recurrence 1 yr after transplantation. Our policy to obtain the kidney presenting anatomical variations proved to be beneficial for the donor. In case of transmission of cancer partial resection preserving graft function might be justified.

Partielle k-Raum-Auslesung mit Null-Interpolation bei Phasenkontrast-Flussmessungen: In-vivo- und In-vitro-Validierung

PURPOSE

To validate the technique of partial k-space sampling and zero filling with phase-contrast flow measurements as compared to measurements with full k-space sampling.

MATERIALS AND METHODS

In vitro: A laminar flow phantom was utilized to evaluate the effect of partial k-space sampling on the accuracy, precision and signal-to-noise ratio of phase-contrast flow measurements. In vivo: The effect of partial k-space sampling on the quantification of cardiac output (n = 40 patients) and the duration of the scan were evaluated in the ascending aorta (n = 37) and pulmonary trunk (n = 34) in a prospective study.

RESULTS

Partial k-space sampling resulted in an increase in the SNR by 2 % in vitro. The precision was altered by less than 1 %. Flow volumes were systematically overestimated by 3.5 %. No significant differences were found in the in vivo measurements of cardiac output. The scan duration was reduced by 34 % by utilizing partial k-space sampling.

CONCLUSION

Partial k-space sampling can be used to reduce scan time without a significant decrease in the accuracy or precision of phase-contrast flow measurements in large arteries.

Unilateral Fasciitis of the Lower Leg

We report an elderly woman with a 3-month history of abdominal pain and painful swelling of her right lower leg. Magnetic resonance imaging revealed extensive fasciitis of the right superficial and deep crural fasciae. Endoscopic ultrasonography identified a tumor in the tail region of the pancreas with regional lymphatic nodal disease and suspicion of liver metastasis. The temporal relationship between the fasciitis and the pancreatic tumor suggests cancer-associated fasciitis-panniculitis syndrome. We report for the first time the incidence of the fasciitis-panniculitis syndrome in a patient with a previously undiagnosed solid pancreatic tumor.

Femoral avulsion fracture of the posterior cruciate ligament in association with a rupture of the popliteal artery in a 9-year-old boy: a case report

Ruptures of the posterior cruciate ligament (PCL) and especially proximal bony avulsion fractures in children are very rare. This in combination with a rupture of the popliteal artery is extremely rare. Thus, an exact incidence is not available from the literature. Overall, these injuries are severe and often lead to chronic knee instability. We report a case of a 9-year-old boy who suffered a traumatic displacement of the left knee with a rupture of the popliteal artery. Prior to transfer to our department, he was treated by a saphenous vein bypass graft and by a transfixation of the knee using two oblique percutaneous pins. We performed magnetic resonance imaging (MRI) scan of the knee which revealed a femoral avulsion fracture of the PCL. Other ligaments and menisci were intact. A transosseous femoral fixation using non-absorbable stitches was carried out. A 1-year follow-up after surgery demonstrates intact peripheral perfusion and sensation, straight axes of both legs and a physiological gait. Minimal differences of the length and circumference of both legs could be measured. The posterior laxity (Lachman-test) was about 5/8 mm (right/left knee) and 2/5 mm (right/left knee) in 90 degrees flexion. The range of motion (extension/flexion) was 5/0/140 degrees -/5/100 degrees (right-left knee). Intact cruciate ligaments were confirmed by MRI. Minimal experience exists in treatment of combined injuries to the PCL and the popliteal artery in children.