Objective
To investigate the impact of an artificial intelligence (AI) software and quantitative ADC (qADC) on the inter-reader agreement, diagnostic performance, and reporting times of prostate ...biparametric MRI (bpMRI) for experienced and inexperienced readers.
Materials and methods
A total of 170 multiparametric MRI (mpMRI) of patients with suspicion of prostate cancer (PCa) were retrospectively reviewed by one experienced and one inexperienced reader three times, following a wash-out period. First, only the bpMRI sequences, including T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI) sequences, and apparent diffusion coefficient (ADC) maps, were used. Then, bpMRI and quantitative ADC values were used. Lastly, bpMRI and the AI software were used. Inter-reader agreement between the two readers and between each reader and the mpMRI original reports was calculated. Detection rates and reporting times were calculated for each group.
Results
Inter-reader agreement with respect to mpMRI was moderate for bpMRI, Quantib, and qADC for both the inexperienced (weighted k of 0.42, 0.45, and 0.41, respectively) and the experienced radiologists (weighted k of 0.44, 0.46, and 0.42, respectively). Detection rate of PCa was similar between the inexperienced (0.24, 0.26, and 0.23) and the experienced reader (0.26, 0.27 and 0.27), for bpMRI, Quantib, and qADC, respectively. Reporting times were lower for Quantib (8.23, 7.11, and 9.87 min for the inexperienced reader and 5.62, 5.07, and 6.21 min for the experienced reader, for bpMRI, Quantib, and qADC, respectively).
Conclusions
AI and qADC did not have a significant impact on the diagnostic performance of both readers. The use of Quantib was associated with lower reporting times.
The Vesical Imaging-Reporting and Data System (VI-RADS) has been introduced to provide preoperative bladder cancer staging and has proved to be reliable in assessing the presence of muscle invasion ...in the pre-TURBT (trans-urethral resection of bladder tumor). We aimed to assess through a systematic review and meta-analysis the inter-reader variability of VI-RADS criteria for discriminating non-muscle vs. muscle invasive bladder cancer (NMIBC, MIBC). PubMed, Web of Science, Cochrane, and Embase were searched up until 30 July 2020. The Quality Appraisal of Diagnostic Reliability (QAREL) checklist was utilized to assess the quality of included studies and a pooled measure of inter-rater reliability (Cohen’s Kappa κ and/or Intraclass correlation coefficients (ICCs)) was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate the contribution of moderators to heterogeneity. In total, eight studies between 2018 and 2020, which evaluated a total of 1016 patients via 21 interpreting genitourinary (GU) radiologists, met inclusion criteria and were critically examined. No study was considered to be significantly flawed with publication bias. The pooled weighted mean κ estimate was 0.83 (95%CI: 0.78–0.88). Heterogeneity was present among the studies (Q = 185.92, d.f. = 7, p < 0.001; I2 = 92.7%). Meta-regression analyses showed that the relative % of MIBC diagnosis and cumulative reader’s experience to influence the estimated outcome (Coeff: 0.019, SE: 0.007; p= 0.003 and 0.036, SE: 0.009; p = 0.001). In the present study, we confirm excellent pooled inter-reader agreement of VI-RADS to discriminate NMIBC from MIBC underlying the importance that standardization and reproducibility of VI-RADS may confer to multiparametric magnetic resonance (mpMRI) for preoperative BCa staging.
Purpose
To determine the clinical, pathological, and radiological features, including the Vesical Imaging-Reporting and Data System (VI-RADS) score, independently correlating with muscle-invasive ...bladder cancer (BCa), in a multicentric national setting.
Method and Materials
Patients with BCa suspicion were offered magnetic resonance imaging (MRI) before trans-urethral resection of bladder tumor (TURBT). According to VI-RADS, a cutoff of ≥ 3 or ≥ 4 was assumed to define muscle-invasive bladder cancer (MIBC). Trans-urethral resection of the tumor (TURBT) and/or cystectomy reports were compared with preoperative VI-RADS scores to assess accuracy of MRI for discriminating between non-muscle-invasive versus MIBC. Performance was assessed by ROC curve analysis. Two univariable and multivariable logistic regression models were implemented including clinical, pathological, radiological data, and VI-RADS categories to determine the variables with an independent effect on MIBC.
Results
A final cohort of 139 patients was enrolled (median age 70 IQR: 64, 76.5). MRI showed sensitivity, specificity, PPV, NPV, and accuracy for MIBC diagnosis ranging from 83–93%, 80–92%, 67–81%, 93–96%, and 84–89% for the more experienced readers. The area under the curve (AUC) was 0.95 (0.91–0.99). In the multivariable logistic regression model, the VI-RADS score, using both a cutoff of 3 and 4 (
P
< .0001), hematuria (
P
= .007), tumor size (
P
= .013), and concomitant hydronephrosis (
P
= .027) were the variables correlating with a bladder cancer staged as ≥ T2. The inter-reader agreement was substantial (
k
= 0.814).
Conclusions
VI-RADS assessment scoring proved to be an independent predictor of muscle-invasiveness, which might implicate a shift toward a more aggressive selection approach of patients’ at high risk of MIBC, according to a novel proposed predictive pathway.
Background
Metastases from endometrial carcinoma to the lungs are uncommon and cavitating metastases are even rarer. In some cases, lung cavitating metastases may resemble diffuse “Cheerios in the ...lung.”
Case presentation
A 58-year-old woman, smoker, with a history of hysteroannessiectomy and pelvic lymphadenectomy for a low stage endometrial endometrioid adenocarcinoma, came under our attention for dry cough without fever that persisted for over three months, and computed tomography (CT) revealed diffuse cavitating lung metastases resembling "Cheerios in the lung".
After standard chemotherapy proved ineffective, Lenvatinib plus Pembrolizumab (immunotherapy) was administrated, leading to the disappearance of all lung nodules, leaving behind a diffuse emphysematous-like pattern.
Conclusions
This case is a rare example of metastatic endometrioid adenocarcinoma, manifested with chronic dry cough, with “Cheerios in the lung” appearence. The metastases responded well to immunotherapy, resulting in the regression of nodules into areas of diffuse emphysematous-like changes.
Background
Among all benign kidney lesions, renal cysts are the most common type. In the proposed update of 2019, the Bosniak classification of cystic renal masses is used to classify renal masses ...according to their likelihood of malignancy, both on computed tomography (CT) and on magnetic resonance imaging (MRI).
Case presentation
A middle-aged Caucasian male presented to our department with chronic right flank pain. Imaging studies revealed a right renal Bosniak IIF cyst, later complicated by traumatic haemorrhage. The patient consequently underwent cyst decortication for symptom relief. Biopsy results from samples taken during the laparoscopic operation revealed ISUP grade 1 cystic clear cell carcinoma.
Conclusion
The treatment of Bosniak IIF cysts has long been a matter of debate. As a result of scarcity of data on the probability of malignancy in MRI using the new classification, such cysts should be carefully scrutinised and staged before choosing a treatment option. Retroperitoneal seeding should always be considered in interventions involving an incomplete resection margin or cyst drainage.
Background
Prostate magnetic resonance imaging (MRI) is technically demanding, requiring high image quality to reach its full diagnostic potential. An automated method to identify diagnostically ...inadequate images could help optimize image quality.
Purpose
To develop a convolutional neural networks (CNNs) based analysis pipeline for the classification of prostate MRI image quality.
Study Type
Retrospective.
Subjects
Three hundred sixteen prostate mpMRI scans and 312 men (median age 67).
Field Strength/Sequence
A 3 T; fast spin echo T2WI, echo planar imaging DWI, ADC, gradient‐echo dynamic contrast enhanced (DCE).
Assessment
MRI scans were reviewed by three genitourinary radiologists (V.P., M.D.M., S.C.) with 21, 12, and 5 years of experience, respectively. Sequences were labeled as high quality (Q1) or low quality (Q0) and used as the reference standard for all analyses.
Statistical Tests
Sequences were split into training, validation, and testing sets (869, 250, and 120 sequences, respectively). Inter‐reader agreement was assessed with the Fleiss kappa. Following preprocessing and data augmentation, 28 CNNs were trained on MRI slices for each sequence. Model performance was assessed on both a per‐slice and a per‐sequence basis. A pairwise t‐test was performed to compare performances of the classifiers.
Results
The number of sequences labeled as Q0 or Q1 was 38 vs. 278 for T2WI, 43 vs. 273 for DWI, 41 vs. 275 for ADC, and 38 vs. 253 for DCE. Inter‐reader agreement was almost perfect for T2WI and DCE and substantial for DWI and ADC. On the per‐slice analysis, accuracy was 89.95% ± 0.02% for T2WI, 79.83% ± 0.04% for DWI, 76.64% ± 0.04% for ADC, 96.62% ± 0.01% for DCE. On the per‐sequence analysis, accuracy was 100% ± 0.00% for T2WI, DWI, and DCE, and 92.31% ± 0.00% for ADC. The three best algorithms performed significantly better than the remaining ones on every sequence (P‐value < 0.05).
Data Conclusion
CNNs achieved high accuracy in classifying prostate MRI image quality on an individual‐slice basis and almost perfect accuracy when classifying the entire sequences.
Evidence Level
4
Technical Efficacy
Stage 1
Objectives
To evaluate MRI diagnostic performance in detecting clinically significant prostate cancer (csPCa) in peripheral-zone PI-RADS 4 lesions, comparing those with clearly restricted diffusion ...(DWI-score 4), and those with equivocal diffusion pattern (DWI-score 3) and positive dynamic contrast-enhanced (DCE) MRI.
Methods
This observational prospective study enrolled 389 men referred to MRI and, if positive (PI-RADS 3 with PSA-density PSAD ≥ 0.15 ng/mL/mL, 4 and 5), to MRI-directed biopsy. Lesions with DWI-score 3 and positive DCE were classified as “PI-RADS 3up,” instead of PI-RADS 4. Univariable and multivariable analyses were implemented to determine features correlated to csPCa detection.
Results
Prevalence of csPCa was 14.5% and 53.3% in PI-RADS categories 3up and 4, respectively (
p
< 0.001). MRI showed a sensitivity of 100.0%, specificity 40.9%, PPV 46.5%, NPV 100.0%, and accuracy 60.9% for csPCa detection. Modifying the threshold to consider MRI positive and to indicate biopsy (same as previously described, but PI-RADS 3up only when associated with elevated PSAD), the sensitivity changed to 93.9%, specificity 57.2%, PPV 53.0%, NPV 94.8%, and accuracy 69.7%. Age (
p
< 0.001), PSAD (
p
< 0.001), positive DWI (
p
< 0.001), and PI-RADS score (
p
= 0.04) resulted in independent predictors of csPCa.
Conclusions
Most cases of PI-RADS 3up were false-positives, suggesting that upgrading peripheral lesions with DWI-score 3 to PI-RADS 4 because of positive DCE has a detrimental effect on MRI accuracy, decreasing the true prevalence of csPCa in the PI-RADS 4 category. PI-RADS 3up should not be upgraded and directed to biopsy only if associated with increased PSAD.
Key Points
•
As per PI-RADS v2.1 recommendations, in case of a peripheral zone lesion with equivocal diffusion-weighted imaging (DWI score 3), but positive dynamic contrast-enhanced (DCE) MRI, the overall PI-RADS score should be upgraded to 4
.
•
The current PI-RADS recommendation of upgrading PI-RADS 3 lesions of the peripheral zone to PI-RADS 4 because of positive DCE decreased clinically significant prostate cancer detection rate in our series.
•
According to our results, the most accurate threshold for setting indication to prostate biopsy is PI-RADS 3 or PI-RADS 3 with positive DCE both associated with increased PSA density.
Objectives
(I) To determine Vesical Imaging‐Reporting and Data System (VI‐RADS) score 5 accuracy in predicting locally advanced bladder cancer (BCa), so as to potentially identify those patients who ...could avoid the morbidity of deep transurethral resection of bladder tumour (TURBT) in favour of histological sampling‐TUR prior to radical cystectomy (RC). (II) To explore the predictive value of VI‐RADS score 5 on time‐to‐cystectomy (TTC) outcomes.
Patients and Methods
We retrospectively reviewed patients’ ineligible or refusing cisplatin‐based combination neoadjuvant chemotherapy who underwent multiparametric magnetic resonance imaging (mpMRI) of the bladder prior to staging TURBT followed by RC for muscle‐invasive BCa. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated for VI‐RADS score 5 vs. score 2–4 cases to assess the accuracy of mpMRI for extravesical BCa detection (≥pT3). VI‐RADS score performance was assessed by receiver operating characteristics curve analysis. A Κ statistic was calculated to estimate mpMRI and pathological diagnostic agreement. The risk of delayed TTC (i.e. time from initial BCa diagnosis of >3 months) was assessed using multivariable logistic regression model.
Results
A total of 149 T2–T4a, cN0–M0 patients (VI‐RADS score 5, n = 39 vs VI‐RADS score 2–4, n = 110) were examined. VI‐RADS score 5 demonstrated sensitivity, specificity, PPV and NPV, in detecting extravesical disease of 90.2% (95% confidence interval CI 84–94.3), 98.1% (95% CI 94–99.6), 94.9% (95% CI 89.6–97.6) and 96.4% (95% CI 91.6–98.6), respectively. The area under the curve was 94.2% (95% CI 88.7–99.7) and inter‐reader agreement was excellent (Κinter 0.89). The mean (SD) TTC was 4.2 (2.3) and 2.8 (1.1) months for score 5 vs 2–4, respectively (P < 0.001). VI‐RADS score 5 was found to independently increase risk of delayed TTC (odds ratio 2.81, 95% CI 1.20–6.62).
Conclusion
The VI‐RADS is valid and reliable in differentiating patients with extravesical disease from those with muscle‐confined BCa before TURBT. Detection of VI‐RADS score 5 was found to predict significant delay in TTC independently from other clinicopathological features. In the future, higher VI‐RADS scores could potentially avoid the morbidity of extensive primary resections in favour of sampling‐TUR for histology. Further prospective, larger, and multi‐institutional trials are required to validate clinical applicability of our findings.
Objective
The purpose of the study was to evaluate the effect of an interactive training program on the learning curve of radiology residents for bladder MRI interpretation using the VI-RADS score.
...Methods
Three radiology residents with minimal experience in bladder MRI served as readers. They blindly evaluated 200 studies divided into 4 subsets of 50 cases over a 3-month period. After 2 months, the first subset was reassessed, resulting in a total of 250 evaluations. An interactive training program was provided and included educational lessons and case-based practice. The learning curve was constructed by plotting mean agreement as the ratio of correct evaluations per batch. Inter-reader agreement and diagnostic performance analysis were performed with kappa statistics and ROC analysis.
Results
As for the VI-RADS scoring agreement, the kappa differences between pre-training and post-training evaluation of the same group of cases were 0.555 to 0.852 for reader 1, 0.522 to 0.695 for reader 2, and 0.481 to 0.794 for reader 3. Using VI-RADS ≥ 3 as cut-off for muscle invasion, sensitivity ranged from 84 to 89% and specificity from 91 to 94%, while the AUCs from 0.89 (95% CI:0.84, 0.94) to 0.90 (95% CI:0.86, 0.95). Mean evaluation time decreased from 5.21 ± 1.12 to 3.52 ± 0.69 min in subsets 1 and 5. Mean grade of confidence improved from 3.31 ± 0.93 to 4.21 ± 0.69, in subsets 1 and 5.
Conclusion
An interactive dedicated education program on bladder MRI and the VI-RADS score led to a significant increase in readers’ diagnostic performance over time, with a general improvement observed after 100–150 cases.
Key Points
• After the first educational lesson and 100 cases were interpreted, the concordance on VI-RADS scoring between the residents and the experienced radiologist was significantly higher.
• An increase in the grade of confidence was experienced after 100 cases.
• We found a decrease in the evaluation time after 150 cases.
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