Publications

Rapid histologic assessment of fresh prostate biopsies may reduce patient anxiety, aid in biopsy sampling, and enable specimen triaging for molecular/genomic analyses and research that could benefit from fresh tissue analysis. Nonlinear microscopy (NLM) is a fluorescence microscopy technique that can produce high-resolution images of freshly excised tissue resembling formalin-fixed paraffin-embedded (FFPE) H&E. NLM enables evaluation of tissue up to  100 µm below the surface, analogous to serial sectioning, but without requiring microtome sectioning. One hundred and seventy biopsies were collected from 63 patients who underwent in-bore MRI or MRI/ultrasound fusion biopsy procedures. Biopsies were stained in acridine orange and sulforhodamine 101, a nuclear and cytoplasmic/stromal fluorescent dye, for 45 s. Genitourinary pathologists evaluated the biopsies using NLM by translating the biopsies in real time to areas of interest and NLM images were recorded. After NLM evaluation, the biopsies were processed for standard FFPE H&E and similarities and differences between NLM and FFPE H&E were investigated. Accuracies of NLM diagnoses and Gleason scores were calculated using FFPE histology as the gold standard. Pathologists achieved a 92.4% sensitivity (85.0-96.9%, 95% confidence intervals) and 100.0% specificity (94.3-100.0%) for detecting carcinoma compared to FFPE histology. The agreement between the Grade Group determined by NLM versus FFPE histology had an unweighted Cohen's Kappa of 0.588. The average NLM evaluation time was 2.10 min per biopsy (3.08 min for the first 20 patients, decreasing to 1.54 min in subsequent patients). Further studies with larger patient populations, larger number of pathologists, and multiple institutions are warranted. NLM is a promising method for future rapid evaluation of prostate needle core biopsies.

BACKGROUND AND PURPOSE: Although the cerebellar tonsils are parasagittal structures, the extent of tonsillar herniation (ETH) in Chiari I malformation (CMI) is currently measured in the midsagittal plane. We measured the ETH of each cerebellar tonsil in the parasagittal plane and assessed their diagnostic utility by comparing them to the midsagittal ETH measurements in predicting cough-associated headache (CAH), an indicator of clinically significant disease in CMI.

METHODS: Eighty-five CMI patients with 3D-MPRAGE images were included. Neurosurgeons determined the presence of CAH. Sagittal images were used to measure ETH in the midsagittal (MS_ETH) and parasagittal planes (by locating tonsillar tips on each side on reformatted coronal images). Given the parasagittal ETH (PS_ETH) asymmetry in the majority of cases, they were considered Smaller_PS_ETH or Larger_PS_ETH. The accuracy of ETH measurements was assessed by the receiver operating characteristic (ROC) curve.

RESULTS: Of 85 patients, 46 reported CAH. ROC analysis showed an area under the curve (AUC) of 0.78 for Smaller_PS_ETH significantly better than 0.65 for MS-ETH in predicting CAH (p = 0.001). An AUC of 0.68 for Larger_PS_ETH was not significantly different from MS_ETH. The sensitivity and specificity of predicting CAH were 87% and 28% for MS_ETH >6 mm versus 90% and 46% for Smaller_PS_ETH >6 mm, and 52% and 67% for MS_ETH >9 mm versus 48% and 87% for Smaller_PS_ETH >9 mm. At ETH >15 mm, no differences were seen between the measurements.

CONCLUSIONS: Diagnostic utility of ETH measurements in detecting clinically significant CMI can be improved by parasagittal measurements of the cerebellar tonsillar herniation.

PURPOSE: MRI is currently the gold standard imaging modality in the diagnosis of lumbar spine discitis/osteomyelitis. However, even with supportive clinical and laboratory data, the accuracy of MRI remains limited by several degenerative and inflammatory mimics, such that it continues to represent a challenge for radiologists. This study reports a new quantitative imaging marker of lumbar paraspinal soft tissue edema which shows significant accuracy for spondylodiscitis.

METHODS: Thirty-five patients with equivocal MRI findings of lumbar discitis/osteomyelitis vs endplate degenerative changes were reviewed over a 24-month period. Patients with a history of surgery, fractures/recent trauma, signs of advanced infection such as abscesses, phlegmon or severe osseous destruction were excluded. Two ABR board certified neuroradiologists who were blinded to the final diagnosis evaluated a new marker; the superior-inferior paraspinal edema ratio (SI-PER). The SI-PER was obtained by measuring the superior-inferior extent of increased signal/edema in the paraspinal soft tissues on the paraspinal inversion recovery images divided by the vertebral body height measured at midpoint. Cases positive for spondylodiscitis were those confirmed by biopsy, aspiration/drainage, surgery, or clinical improvement following antibiotic treatment. The diagnostic sensitivity and specificity of SI-PER were determined by Receiver operating characteristic (ROC) analysis.

RESULTS: In 23/35 (66%) patients, the diagnosis of discitis/osteomyelitis was confirmed. The SI-PER showed a significant association with a positive MRI diagnosis (p = 0.001). Inter-observer correlation for SI-PER was 0.92. ROC analysis showed an area under the curve of 0.84. A SI-PER of 2.5 was 96% sensitive and 75% specific for the diagnosis of discitis/osteomyelitis, with a PPV of 88% and a NPV of 90%.

CONCLUSION: In this study, the superior inferior paraspinal edema ratio (SI-PER), a newly defined MRI marker, was found to have high sensitivity for differentiating spondylodiscitis from endplate degenerative changes on lumbar spine MRI.

See also the editorial by Ronot in this issue. Online supplemental material is available for this article.

BACKGROUND AND AIMS: EUS is increasingly used to evaluate patients with liver disease, but its role in assessing hepatic steatosis has not been reported. The goal of our study was to assess the accuracy of EUS for diagnosing hepatic steatosis.

METHODS: We identified all patients who underwent EUS-guided liver biopsy sampling at our institution. All digitally stored EUS liver images were reviewed by a single radiologist, who rated the severity of liver echogenicity using a 4-point US scale. Liver biopsy specimens for all study patients were reviewed by a single liver pathologist, who rated them for steatosis and fibrosis using Nonalcoholic Steatohepatitis Clinical Research Network criteria. Receiver operator characteristic curves were used to assess the diagnostic accuracy of EUS for hepatic steatosis for all patients and in a subgroup analysis for obese and nonobese patients.

RESULTS: During the study period, 76 patients underwent EUS-guided liver biopsy sampling. The average age of study patients was 56.5 years, 50% were women, and 43.2% were obese. The accuracy for EUS for the diagnosis of hepatic steatosis was .8 (95% confidence interval [CI], .7-.89). The accuracy of EUS for the diagnosis of hepatic steatosis in obese patients was .93 (95% CI, .8-.99) and in nonobese patients was .69 (95% CI, .54-.83). For obese patients, EUS had a positive predictive value of 89.7% and a negative predictive value of 75%. The finding of course echotexture on EUS had an accuracy of 79% for the diagnosis of grade 3 fibrosis or cirrhosis.

CONCLUSIONS: EUS is a useful tool for the diagnosis of hepatic steatosis, particularly in obese patients in whom abdominal US has modest accuracy.

BACKGROUND AND PURPOSE: Spinal cord compression (SCC) requires rapid diagnosis in the emergent setting; however, current MRI protocols may be cumbersome for patients and clinicians. We sought to validate an abbreviated total spine MRI (TS-MRI) protocol using standard non-contrast sequences in the detection of SCC and other clinically significant findings (OCSF).

METHODS: Two hundred six TS-MRI scans obtained over a 30-month period for SCC were included. Sagittal T2 (T2sag), sagittal T1 (T1sag), and sagittal STIR (IRsag), as well as axial T2 (T2ax) images, were individually assessed independently by 2 reviewers for SCC, cauda equina compression (CEC), and OCSF. A protocol consisting of all the sequences was considered the gold standard. Sensitivity and specificity of single and combined MRI sequences for SCC/CEC and OCSF were determined and were tested for noninferiority relative to standard non-contrast sequences using a 5% noninferiority margin.

RESULTS: An abbreviated protocol of IRsag + T2ax provided the best performance with sensitivity and specificity of 100% (95%CI, 96.0-100.0) and 98.6% (95%CI, 95.6-99.7) for SCC/CEC and 100.0% (95%CI, 96.7-100.0), and 99.3% (95%CI, 96.6-99.9) for OCSF. The mean difference of sensitivity and specificity between IRsag + T2ax and standard protocol was 0.0% (95%CI, 0.0-4.0) and - 2.1% (95%CI, - 5.4 to - 0.6) for SCC/CEC and 0.0% (95%CI, 0.0-3.3) and - 1.5% (95%CI, - 4.8 to - 0.3) for OCSF, all within the noninferiority margin of 5%.

CONCLUSIONS: An abbreviated TS-MRI protocol of IRsag + T2ax is noninferior to the standard non-contrast protocol, potentially allowing for faster emergent imaging diagnosis and triage.

PURPOSE: As men age, the prostate continues to grow on average 2.5% per year. While the variable growth rate of the total prostate gland is recognized, the growth rate of different prostate zones remains largely unclear. We evaluated the growth patterns of the prostate zones and identified clinical parameters contributing to the zonal growth rates.

MATERIALS AND METHODS: Prostate magnetic resonance imaging (MRI) data and clinical information were obtained retrospectively on 156 patients who had at least 3 prostate MRIs between 2003 and 2018. Different prostate zonal volumes were measured and analyzed. The outcome was analyzed using linear regression.

RESULTS: We observed that prostate growth rates vary depending on body mass index (BMI), transition zone index (TZI), the prostate zone and 5-alpha reductase inhibitor (5ARI) use. The peripheral zone volume growth rates increased with age and peaked at 60-70 years of age (p=0.047), while the transition zone volume demonstrates continuous growth without a peak through all ages. BMI and TZI are associated with the growth rate of the peripheral zone (p=0.026, p <0.001, respectively) but not the transition zone growth rate. 5ARI use is significantly associated with the reduction in the transition zone growth rate (p=0.033), not the peripheral zone. In addition, patients with TZI greater than 60% had the most significant reduction in the transition zone growth rate while taking 5ARI (p <0.001).

CONCLUSIONS: Transition and peripheral zones of the prostate grow at variable rates. BMI and TZI affect peripheral zone growth rate, while 5ARI use reduces the transition zone growth rate.

BACKGROUND. Heart failure (HF) is an uncommon complication after TIPS placement; its development represents a poor prognostic factor. OBJECTIVE. The purpose of our study was to evaluate the frequency, risk factors, and association with survival of HF developing within 90 days after TIPS placement in patients with cirrhosis. METHODS. This retrospective single-center study included patients with cirrhosis who underwent nonemergent covered-stent TIPS placement from June 2003 to December 2018 and who underwent echocardiography within 2 months before TIPS placement and had at least 90 days of post-TIPS follow-up. Development of HF within 90 days after TIPS was recorded. Frequency of TIPS reduction for post-TIPS HF was determined. Univariable logistic regression analysis and ROC curve analysis were performed to assess potential risk factors for post-TIPS HF. Association of post-TIPS HF and 1-year survival was assessed by the log rank test. RESULTS. The study sample included 107 patients (71 men and 36 women; median age, 58 years). Post-TIPS HF developed in 11 of 107 (10%) patients; median time to development of HF was 16 days (range, 2-62 days). Of these 11 patients, three (27%) required TIPS reduction to achieve resolution of HF symptoms after unsuccessful diuretic therapy. Pre-TIPS right atrium size (odds ratio [OR], 3.26 [95% CI, 1.22-10.16]; p = .03], left ventricle (LV) end-systolic dimension (OR, 5.43 [95% CI, 1.44-24.50], p = .02), LV end-diastolic dimension (OR, 4.12 [95% CI, 1.51-13.47]; p = .009), and estimated peak pulmonary artery systolic pressure (PASP) (OR, 1.27 [95% CI, 1.12-1.50]; p = .001) were associated with post-TIPS HF. AUC of right atrium size, LV end-systolic dimension, LV end-diastolic dimension, and estimated peak PASP for development of post-TIPS HF were 0.71, 0.74, 0.72, and 0.83, respectively. At a cutoff of 31 mm Hg, PASP achieved sensitivity of 70% and specificity of 86% for post-TIPS HF. Patients with post-TIPS HF and those without post-TIPS HF had 1-year survival of 46% versus 73% (p = .06). CONCLUSION. Multiple pre-TIPS echocardiographic variables predict the development of post-TIPS HF in patients with cirrhosis. CLINICAL IMPACT. Preprocedural echocardiography may guide risk stratification in patients with cirrhosis being considered for TIPS placement.