BACKGROUND/AIMS:The aim of this study was to compare the efficacy and tolerability of topiramate and propranolol in preventing pediatric cyclic vomiting syndrome. METHODS:A retrospective medical-record review of patients who underwent prophylaxis after receiving a diagnosis of cyclic vomiting syndrome was performed. Patients who completed at least 12 months of treatment were included in the analysis. Responder rate, and adverseevent rates were also calculated from all patients. Response to treatment was assessed as the total number of vomiting attacks per year. Patients in whom the frequency of vomiting attack reduced greater or equal to 50% were defined as responders, and the remaining patients were classified as nonresponders. RESULTS:A total of 38 patients who were treated prophylactically with either topiramate (16 patients) or propranolol (22 patients) were identified. Fifty-nine percent of the patients in the propranolol group and 81% of the patients in the topiramate group reported freedom from attacks. A decrease of more than 50% in attacks per year occurred in 23% of patients in the propranolol group and 13% of patients in the topiramate group. The responder rates were 81% for propranolol group and 94% for topiramate group (P = 0.001). Despite minor adverse effects (drowsiness, nervousness, and dizziness) observed in a few patients, the adverse event rates were not significantly different between the 2 groups (P = 0.240). CONCLUSIONS:The efficacy of topiramate was superior to propranolol for the prophylaxis of pediatric cyclic vomiting syndrome.

Purpose To evaluate predictors of false-positive (FP) and false-negative (FN) results for prostate cancer at prostate multiparametric MRI (mpMRI) using the Prostate Imaging and Reporting Data System version 2 (PI-RADS v2). Materials and Methods This was a single-center retrospective cohort study of 2548 consecutive patients who underwent prostate mpMRI examinations (October 2016-July 2022) containing zero or one PI-RADS v2 category 3-5 lesions. Prostate mpMRI examinations were interpreted by 13 radiologists. FP results were defined as prospective PI-RADS v2 score of 3 or higher but benign or grade group 1 prostate cancer at subsequent combined targeted and systematic biopsy. FN results were defined as prospective PI-RADS v2 score 2 or lower but grade group 2 or higher prostate cancer at subsequent combined targeted and systematic biopsy. Predictors of FP and FN results were assessed by logistic regression. Results Among the 2548 patients (mean age, 65.7 years ± 7.6 [SD]; all male) analyzed, 52.0% (831 of 1597) had FP results and 15.8% (150 of 951) had FN results at mpMRI. FP results were more likely for younger patients (odds ratio [OR], 0.95/y; P < .001), smaller lesions (OR, 0.62/mm; P < .001), transition zone lesions (OR, 1.74 vs peripheral zone; P = .006), and patients with low prostate-specific antigen (PSA) density (OR, 0.55 per 0.1 ng/mL2 increase; P < .001). FN results were more likely for older patients (OR, 1.03/y; P = .01) and patients with high PSA density (OR, 2.05 per 0.1 ng/mL2 increase; P < .001). Conclusion PSA density and patient age independently predicted FP and FN results for detection of prostate cancer at mpMRI using PI-RADS v2. These factors are not part of the PI-RADS v2 algorithm and may inform mpMRI interpretation to improve prostate cancer diagnosis. Keywords: MR Imaging, Prostate, PI-RADS, Prostate MRI, Prostate Cancer ©RSNA, 2025.

OBJECTIVE To determine how many cores should be collected per region of interest (ROI) in magnetic resonance imaging-guided fusion prostate biopsy. Magnetic resonance imaging-guided targeted prostate biopsy has led to improved detection of clinically significant prostate cancer (csPC); however, data is limited regarding the optimal number of biopsy cores that should be taken. An ideal number of cores maximizes clinically significant cancer detection while minimizing cost, discomfort, and procedure time. METHODS Patients receiving targeted prostate biopsy (4 cores per ROI) combined with systematic 12-core prostate at our institution between January 2017 and June 2022 were retrospectively identified. Statistical simulation was used to model scenarios in which 1, 2, 3, or 4 cores were taken from the ROI, and the rate of grade group >= 2 prostate cancer (csPC) detection was determined for targeted and combined targeted plus systematic biopsy. RESULTS 483 patients were identified. Transrectal (96%) and transperineal (4%) biopsies were included. For targeted biopsy, csPC was present in 21% (1 core), 26% (2 cores; P = .048), 29% (3 cores; P = .002), and 31% (4 cores; P < .001) of cases. For combined biopsy, csPC was present in 33% (1 core), 35% (2 cores; P = .4), 37% (3 cores; P = .2), and 38% (4 cores; P = .12) of cases. CONCLUSION If targeted biopsy is performed without systematic biopsy, 2 or more cores is superior to 1 core for detecting csPC. This effect is mitigated when targeted and systematic biopsy are combined. UROLOGY 197: 133-140, 2025. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The expression of diagnostic certainty in radiology reports is common and used to inform clinicians and patients about the degree of confidence a radiologist has in a finding or differential diagnosis. However, radiologists express diagnostic certainty in myriad ways, which leads to ambiguity and risk of misdirected clinical management. Standardizing how diagnostic certainty is expressed is likely to improve the fidelity of information transfer between radiologists and referring providers and patients. In recognition of the need to improve the clarity of diagnostic tests, the American College of Radiology Commission on Quality and Safety convened a working group of radiologists with expertise and interest in radiology reporting and diagnostic communication. The group's task was to summarize current knowledge and challenges in the expression of diagnostic certainty in radiology reports, and to offer recommendations for establishing greater consensus. Although there is insufficient agreement at this time to formally recommend one diagnostic certainty scale over another, two examples from single-site experiences and one consensus scale favored by this writing group are provided for consideration and pilot testing by radiology practices.

This study explores the impact of physician experience, specialty, and institutional background on the performance of AI-assisted assessment of treatment responses in bladder cancer patients. Utilizing pre- and post-chemotherapy CTU scans from 123 patients, 17 physicians with varying levels of experience and from different specialties and institutions assessed 157 lesion pairs. The lesion pairs were divided into easy and difficult cases to evaluate the AI system's effectiveness in different scenarios. The study revealed that AI assistance significantly improved diagnostic accuracy in easy cases for both experienced and inexperienced physicians, with a great benefit observed in radiologists and oncologists. In difficult cases, the AI's impact was present but less pronounced, indicating that while AI can enhance performance in challenging situations, its effectiveness is more limited in complex cases. Additionally, the study found that institutional background influenced the effectiveness of AI assistance, suggesting that certain training or cultural factors may affect physicians' trust in AI recommendations. The findings underscore the potential of AI to support clinical decision-making in bladder cancer treatment response assessment, particularly in less complex cases. However, they also highlight the need for tailored implementation and user training of AI systems to maximize their effectiveness across different medical specialties and institutions. By aligning AI tools with the specific needs and expertise of physicians, their confidence and efficacy in using AI in complex medical scenarios can be enhanced.

BACKGROUND. Bosniak classification version 2019 (v2019) was a major revision to version 2005 (v2005) that defined cystic renal mass subclasses on the basis of wall or septa features. OBJECTIVE. The purpose of the study was to determine the proportion of malignancy within cystic renal masses stratified by Bosniak classification v2019 class and feature-based subclass. EVIDENCE ACQUISITION. MEDLINE and Embase databases were searched on July 24, 2023, for studies published in 2019 or later that reported cystic renal masses that underwent renal-mass CT or MRI, were assessed using Bosniak classification v2019, and had a reference standard (histopathology indicating benignancy or malignancy or ≥ 5 years of imaging follow-up indicating benignancy). Study authors were contacted to provide subclass-stratified data. Pooled proportions of malignancy stratified by v2019 class and subclass were determined using meta-analysis. EVIDENCE SYNTHESIS. The analysis included 12 studies reporting 966 patients with 975 cystic masses. No class I mass was malignant. Pooled proportions of malignancy by class were as follows: II, 9% (95% CI: 5-17%); IIF, 26% (95% CI: 13-46%); III, 80% (95% CI: 71-87%); and IV, 88% (95% CI: 83-91%). Pooled proportions of malignancy by subclass were as follows: IIF with many smooth, thin septa, 10% (95% CI: 2-33%); IIF with minimal wall or septal thickening, 47% (95% CI: 18-77%); IIF with heterogeneous T1 hyperintensity, 26% (95% CI: 8-57%); III with a thick, smooth wall or septa, 78% (95% CI: 60-90%); III with obtuse protrusion(s) 3 mm or less, 84% (95% CI: 77-90%); IV with acute protrusion(s) of any size, 88% (95% CI: 80-93%); and IV with obtuse protrusion(s) 4 mm or greater, 86% (95% CI: 77-91%). The proportion of malignancy was 41% for IIF masses with histopathology reference versus 2% for IIF masses with imaging follow-up reference. In four studies performing intraindividual comparisons of v2005 versus v2019, the proportions of malignancy were as follows: class IIF, 24% versus 42% (p = .13); III, 74% versus 77% (p = .72); and IV, 79% versus 84% (p = .22). CONCLUSION. Bosniak IIF masses had higher malignancy rates when histopathology rather than imaging follow-up was the reference standard, indicating verification bias. All Bosniak III and IV subclasses had high malignancy rates. CLINICAL IMPACT. The results improve understanding of imaging-based cystic renal-mass classification and may inform development of future renal-mass classification systems. TRIAL REGISTRATION. PROSPERO (International Prospective Register of Systematic Reviews) CRD42023472140.

Introduction and Objectives: Assessing oncological success following focal ablation for prostate cancer (PCa) includes prostate-specific antigen (PSA) response and imaging. However, the value of protocol biopsy remains uncertain. Consensus recommendations include follow-up multiparametric MRI (mpMRI) and biopsy despite variable imaging quality, interpretation, and biopsy performance. We aim to determine mpMRI performance characteristics postablation for early in-field (within the ablation zone) failure following focal cryoablation (FC). Methods: Patients receiving FC from January 1, 2017, to April 21, 2023, at Michigan Medicine were enrolled in a multi-institutional, institutional review board-approved prospective registry. Per protocol, PSA, mpMRI, and ultrasound-MR fusion biopsy of the ablation bed were obtained at 6 to 12 months postablation. Residual PCa was suspected on mpMRI if there was persistent enhancement and impeded diffusion near the ablation zone colocalizing to the intended ablation target. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of postablation mpMRI for Gleason Grade Group (GG) ≥2 PCa were calculated. Chi-squared test was used to perform bivariate analysis. Results: A total of 76 patients underwent primary ablation, postablation mpMRI, and protocol biopsy. Eight patients underwent repeat cryoablation with postsalvage cryoablation mpMRI and biopsy (N = 84 postablation events). Postablation mpMRI showed persistent PCa in 13.4% (11/84). Postablation biopsy showed GG ≥2 PCa in 7.1% (6/84) of target lesions. MpMRI sensitivity, specificity, PPV, and NPV for detecting untreated GG ≥2 PCa postablation were 83.3%, 92.3%, 45.5%, and 98.6%, respectively, with significant association between positive MRI and biopsy detection of GG ≥2 PCa (p < 0.0001). The positive and negative likelihood ratios for residual disease detection were 10.8 and 0.18. Conclusion: Postablation mpMRI has a high sensitivity, NPV, and specificity for detecting untreated GG ≥2 PCa. If negative, near-term "protocol" biopsy may be safely avoided. Investigation into causes of false positive and negative postablation mpMRI will help identify those who warrant per-protocol biopsy.

Despite the successful application of Imaging Reporting and Data Systems to improve the radiologic description and management of disease in many organs, one does not yet exist for the kidney. Instead, the radiologic approach to the kidney has focused on the Bosniak classification system, which is based on imaging characteristics for cystic renal masses, and detecting macroscopic fat within solid renal masses. Radiologically, cystic and solid renal masses are categorized and evaluated separately because of historical precedent, differences in appearance at imaging, and differences in biologic behavior. However, the World Health Organization classification of renal neoplasms does not support such separation. Further, the primary goal has been cancer diagnosis. Differentiating benign from malignant masses is important, but data show that many renal cancers, particularly when small, will not cause harm. Therefore, a critical goal of any unifying, single, imaging-based classification of kidney masses (ie, a Kidney Imaging Reporting and Data System) should be predicting the biologic behavior or aggressiveness of suspected kidney cancer. This system could inform the need for treatment or active surveillance and reduce prevalent overdiagnosis and overtreatment. This review describes the rationale for and challenges in creating such a system and the research needed for it to be developed.

Background & aims: Abbreviated MRI (AMRI) has been proposed as an alternative to ultrasound for hepatocellular carcinoma (HCC) surveillance; however, comparative data for AMRI and ultrasound are needed. Thus, we evaluated the sensitivity and specificity of dynamic contrast-enhanced (DCE)-AMRI and ultrasound for early-stage HCC detection in patients with cirrhosis. Methods: We conducted a multicenter retrospective case-control study among patients with cirrhosis (cases with early-stage HCC as per Milan Criteria; controls without HCC) who underwent an ultrasound and a DCE-MRI within a 6-month period between 2012 and 2019. HCC diagnosis was confirmed by imaging alone in 85% and by histopathology in 15% of patients. Dynamic AMRI examinations were simulated from the full MRI by selecting relevant sequences. Independent, blinded interpretations of ultrasounds and AMRI results were performed using Liver Imaging Reporting and Data System algorithms. Ultrasounds were considered positive if US-3 observations were detected. AMRI was considered positive if LR-4, LR-5, or LR-M were detected. Per-patient sensitivity and specificity for early-stage HCC detection were estimated, and cross-modality differences were tested. Results: We included 216 cases and 432 controls. Patient-level sensitivity and specificity of AMRI were significantly higher compared with ultrasound: 80.1% (95% CI 76.1-83.6) vs. 71.1% (95% CI 66.6-75.2), p <0.001, and 91.9% (95% CI 89.9-93.5) vs. 72.3% (95% CI 69.3-75.2), p <0.001, respectively. AMRI sensitivity was significantly higher compared with ultrasound among patients with Child-Pugh B cirrhosis (80.8% vs. 57.4%, p <0.001) but not among those with Child-Pugh A (84.7% vs. 78.6%, p = 0.07) or Child-Pugh C cirrhosis (52.6% vs. 68.4%, p = 0.18). Conclusions: Dynamic AMRI may be more sensitive and specific for early-stage HCC detection in patients with cirrhosis compared with ultrasound, although its relative benefit might be smaller in patients with Child-Pugh A cirrhosis. Larger direct comparative data sets are needed, particularly among patients with Child-Pugh C cirrhosis who may benefit from alternative surveillance strategies.

Objectives High-resolution anorectal manometry (HRAM) is the established investigation in faecal incontinence (FI). However, provocative tests (functional lumen imaging probe (FLIP) and anal acoustic reflectometry (AAR)) have been proposed as alternatives. This study uniquely explores all three methods in correlation with FI symptoms and subtypes.Methods This was a prospective observational study of patients with FI attending a tertiary pelvic floor unit between August 2022 and January 2024. Patients underwent HRAM, FLIP and AAR with the order randomised. FI severity was assessed with the Vaizey score and quality-of-life with the Manchester Health Questionnaire.Results 40 patients (39 women, median age: 62 (range: 38-85)) were recruited with 27 (67.5%) reporting urge FI, 8 (20%) mixed and 5 (12.5%) passive incontinence. FLIP squeeze measurements correlated with the Vaizey score, including incremental squeeze pressure at 40 mL (rs=-0.412; p=0.008) and 50 mL (rs=-0.414; p=0.009) and the pressure-diameter volume loop at 50 mL (rs=-0.402; p=0.011). Incremental squeeze opening pressure with AAR correlated with the Vaizey score (rs=-0.339; p=0.032). There was no correlation between symptom severity and HRAM parameters, or any parameter and quality-of-life scores. Resting parameters with all three modalities were lower in passive FI: mean resting pressure (HRAM; p=0.010), yield pressure (FLIP; p=0.031) and opening pressure (AAR; p=0.006). With FLIP, there was a trend towards reduced squeeze function in the urge group (pressure-diameter volume loop at 50 mL; p=0.295).Conclusions FLIP and AAR correlate better with FI symptoms compared with HRAM. Therefore, these provocative tests could be used to guide the management of FI in prospective studies.

AbstractThe evidence underlying the use of advanced diagnostic imaging is based mainly on diagnostic accuracy studies and not on well-designed trials demonstrating improved patient outcomes. This has led to an expansion of low-value and potentially harmful patient care and raises ethical issues around the widespread implementation of tests with incompletely known benefits and harms. Randomized clinical trials are needed to support the safety and effectiveness of imaging tests and should be required for clearance of most new technologies. Large, diverse cohort studies are needed to quantify disease risk associated with many imaging findings, especially incidental findings, to enable evidence-based management. The responsibility to minimize the use of tests with unknown or low value requires engagement of clinicians, medical societies, and the public.

OBJECTIVE:To determine whether continuity of care between diagnostic breast imaging and subsequent image-guided breast biopsy could reduce patient-reported biopsy-related morbidity. METHODS:This was a prospective, pragmatically randomized, 2-arm health utilities analysis of 200 women undergoing diagnostic breast imaging followed by US- or stereotactic-guided breast biopsy at a single quaternary care center from September 3, 2019, to April 10, 2023. Breast biopsy-naive women with a BI-RADS 4 or 5 finding at diagnostic imaging were randomly scheduled for the typically first available biopsy appointment. One day after biopsy, enrolled patients were administered the Testing Morbidities Index (TMI). The primary outcome was the difference in TMI summary utility scores in patients who did vs did not have the same radiologist perform diagnostic imaging and biopsy. RESULTS:Response rates were 63% (100/159) for the different radiologist cohort and 71% (100/140) for the same radiologist cohort; all respondents answered all questions in both arms. Mean time to biopsy was 7 ± 6 days and 10 ± 9 days, and the number of participating radiologists was 11 and 18, respectively. There was no difference in individual measured domains (pain, fear, or anxiety before procedure; pain, embarrassment, fear, or anxiety during procedure; mental or physical impact after procedure; all P >.00625) or in overall patient morbidity (0.83 [95% CI, 0.81-0.85] vs 0.82 [95% CI: 0.80-0.84], P = .66). CONCLUSION:Continuity of care between diagnostic breast imaging and image-guided breast biopsy did not affect morbidity associated with breast biopsy, suggesting that patients should be scheduled for the soonest available biopsy appointment rather than waiting for the same radiologist.

In this 10-patient prospective pilot study, we show the feasibility of pragmatic direct ex vivo measurement of gadolinium retention from group II gadolinium-based contrasts agents (GBCAs) in young patients after routine tooth extraction. This noninvasive method may support future research attempting to understand the link between GBCA exposure and clinical outcomes.

Aim: Rectal intussusception (RI) and external rectal prolapse (ERP) are associated with anal sphincter dysfunction. The aim of this study was to examine sphincter function with anal acoustic reflectometry (AAR) in RI and two distinct phenotypes of ERP termed high and low "take-off". Methods: A prospective study of patients with RI and ERP attending a tertiary pelvic floor unit. Clinical data, AAR, and conventional anal manometry were analysed according to the Oxford prolapse grade. Results: A total of 108 (102 [94%] female, median age 62 years [range: 26-95]) patients were recruited into three groups according to prolapse grade: Oxford grades I and II (intrarectal RI, n = 34), Oxford grades III and IV (intra-anal RI, n = 35) and Oxford grade V (ERP, n = 39). As the grade of prolapse increased, resting AAR measurements of opening pressure, opening elastance, closing pressure, and closing elastance decreased (p < 0.001). Maximum resting pressure with manometry was reduced in ERP and intra-anal RI compared to intrarectal RI (p < 0.001). However, incremental squeeze function was not different between the three groups with either AAR or manometry (p > 0.05). There were no differences in AAR or manometry variables between grade IV RI (n = 18) and high take-off ERP (n = 20) (p > 0.05). By contrast, opening pressure (p = 0.010), closing pressure (p = 0.019) and elastance (p = 0.022) were reduced in low take-off ERP (n = 19). Conclusion: Increasing rectal prolapse grade is associated with reduced anal sphincter function at rest indicating internal anal sphincter dysfunction. Physiological differences exist between high and low take-off ERP with sphincter function in the former similar to that seen in grade IV RI.

Purpose:To determine the accuracy of Tc-99 m sestamibi for the diagnosis of acute cholecystitis during a supply chain disruption of mebrofenin. Material and methods:During a national shortage of Tc-99 m mebrofenin in 2019, our institution initiated sestamibi imaging for suspected cases of acute cholecystitis using a standard hepatobiliary imaging protocol. Forty-one patients underwent hepatobiliary imaging with sestamibi, 39 to assess for acute cholecystitis. The examinations were initially interpreted by one nuclear medicine physician and subsequently overread by 5 blinded nuclear medicine physicians (8-30 years' experience). SPECT/CT was obtained for 8 of these patients at the discretion of the primary interpreter. An additional 23 asymptomatic patients (6 with prior cholecystectomy) underwent abdominal scintigraphy as a negative control to determine the normal time to sestamibi accumulation in the gallbladder. A composite reference standard was used (chart review by 3 physicians). Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were calculated with and without SPECT/CT (mean ± 95%CI). Results:Of 39 symptomatic patients, 17/39 had acute cholecystitis and 22 did not. The sensitivity, specificity, PPV and NPV for acute cholecystitis at planar imaging were 97.6 ± 4.6, 62.7 ± 5.2, 67.0 ± 3.6, and 97.3 ± 5.2 % (N = 39). The values changed to 95.7 ± 4.7, 77.9 ± 4.7, 72.1 ± 4.1, and 97.0 ± 3.3 % when control patients were included (N = 62). With SPECT/CT, these mildly improved to 98.8 ± 2.3 %, 69.1 ± 4.4 %, 71.3 ± 3.2 %, and 98.7 ± 2.6 % (N = 39), but not significantly different. On average, sestamibi activity was detected in the gallbladder in negative controls within 1 h. Conclusion:Tc-99 m sestamibi has excellent sensitivity and NPV for diagnosing acute cholecystitis and can serve as an alternative when mebrofenin is unavailable for evaluating cystic duct obstruction during shortages of standard agents.

Introduction Anal acoustic reflectometry (AAR), a novel test of anal sphincter function, was shown to predict a successful trial phase of sacral neuromodulation (SNM) for fecal incontinence. This follow-up study aims to explore if AAR can also predict short- and long-term SNM outcomes at less than and more than 5 y, respectively. Methods Outcome data were reviewed from a prospectively managed database. Successful treatment was defined as >50% improvement in patient reported fecal incontinence or urgency episodes, or in a symptom severity score. Results Twenty-six female patients (median: 53 y [range 31-80]) who received a permanent SNM implant were analyzed. In the short-term, no differences were observed in baseline AAR and symptom severity parameters between patients reporting success or failure. At long-term follow-up (median: 122 mo [113-138]) data was available from 17 (17/26, 65%) patients with 7 (7/17, 41%) reporting continued treatment success. Baseline fecal urgency episodes (P = 0.003), and the AAR parameters of opening elastance (P = 0.043) and squeeze opening elastance (P = 0.025) were significantly different between patients reporting success and those reporting failure. Squeeze opening elastance demonstrated the greatest ability to discriminate between success and failure (area under the curve: 0.82 (95% confidence interval 0.60-1.01, P = 0.003)). Conclusions AAR may have a role in identifying patients suitable for SNM treatment with clinically relevant metrics associated with successful response to treatment. Future work should explore this further to improve SNM patient selection.