OBJECTIVE:To assess the efficacy of prostate artery embolisation (PAE) in the management of obstructive benign prostatic hyperplasia (BPH) by conducting formal urodynamic studies. METHODS:Patients with symptomatic BPH underwent baseline assessments, including urodynamic evaluation, followed by PAE. Follow-up International Prostate Symptom Scores (IPSS), Quality of Life questionnaire (QoL) scores, prostate volume and urodynamic variables were assessed at a mean follow-up of 18 months. RESULTS:A total of 105 patients underwent PAE, with average final follow-up at 18 months. Prostate volumes reduced by a mean of 30.6% and significant improvements were identified across all IPSS parameters (total IPPS decreased by 55%; P < 0.001), QoL scores (improved by 65.9%; P < 0.001), maximum urinary flow rate (increased by 5 mL/s; P < 0.001), postvoid residual urine volume (decreased by 24%; P = 0.049), detrusor pressure (decreased from 65.0 to 48.9 cmH2O; P < 0.001) and bladder obstruction rates. Bladder obstruction decreased from 66.7% to 29.8% of patients following embolisation. Results were found to be positively correlated to the absolute amount of embolic material injected during the embolisation procedure. PAE was well tolerated, with expected post-embolisation symptoms resolving completely after a mean (sd; range) of 7 (±5; 1-28) days. There were no major procedural complications, no reported urinary incontinence, and new retrograde ejaculation occurred in 2%. CONCLUSION:In this study, PAE resulted in statistically significant improvements by both subjective and objective measures, including symptom severity, quality of life and urodynamic parameters. Whilst longer-term studies are required, these findings support PAE as a non-surgical option within the treatment algorithm for managing symptomatic, obstructive BPH.

BACKGROUND:Accurate primary staging of renal cancer with conventional imaging is challenging. Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) may serve to improve the accuracy of renal cancer staging. OBJECTIVE:To determine clinicopathological and management differences for primary renal cancer staged with PSMA PET/CT in comparison to conventional imaging. DESIGN, SETTING, AND PARTICIPANTS:We conducted a retrospective cohort study of PSMA PET/CT scans performed for primary staging of renal cancer and incidental renal lesions at three sites in Brisbane, Australia between June 2015 and June 2020. Clinical characteristics, imaging, and histopathology were reviewed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:Clinicopathological and management differences according to staging modality (PSMA PET/CT, conventional imaging) were assessed. Descriptive statistics were used to report demographics and clinical parameters. Nonparametric methods were used for statistical analysis. Fisher's exact test was used for comparison of small-cell size categorical variables. RESULTS AND LIMITATIONS:From a total of 120 PSMA PET/CT scans, 61 were included (52 staging, 9 incidental) for predominantly males (74%) with a mean age of 65.1 yr (standard deviation 12.0). Most primary lesions (40/51) were clear-cell renal cell carcinoma (ccRCC; 98% PSMA-avid), eight were non-ccRCC (75% PSMA-avid), and three were non-RCC (oncocytoma; 67% PSMA-avid). PSMA PET identified a greater number of presumed metastatic lesions than conventional imaging (195 vs 160). A management change was observed for 32% of patients (20% major, 12% minor). Limitations include the retrospective design and selection bias, lack of blinding to PSMA reporting, and the use of different PSMA radiotracers. CONCLUSIONS:PSMA PET/CT detected more metastases than conventional imaging and most renal cancers were PSMA-avid, resulting in a management change for one-third of the patients. PATIENT SUMMARY:We looked at a newer type of scan called PSMA PET/CT for first staging of kidney cancer. We found that this detects more metastasis and helps in decisions on changes in treatment for some patients. This type of imaging is a useful addition to conventional scans in tricky cases and may help in better selection of suitable treatments, but more studies are required.

ObjectiveTo compare prostate artery embolisation (PAE) to the combination of tamsulosin and dutasteride therapy as a potential first‐line therapy for obstructive benign prostatic hyperplasia (BPH) in treatment‐naïve patients in the ‘Prostate Embolisation AS first‐line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial’ (P‐EASY ADVANCE).Patients and MethodsA total of 39 men with enlarged prostates, moderate–severe lower urinary tract symptoms (LUTS) and obstructed/equivocal urodynamic studies (UDS), and who had no prior treatment for BPH, were randomised to receive either combined medical therapy with tamsulosin and dutasteride (medication) or PAE. Follow‐up UDS, International Prostate Symptom Score (IPSS), uroflowmetry and ultrasound were performed at short‐ to medium‐term intervals following interventions and compared to baseline.ResultsThe medication and PAE treatment groups had similar baseline characteristics, including prostate volumes (87.8 and 85.4 mL respectively), maximum urinary flow rate (Qmax; 6.5 and 6.6 mL/s, respectively), IPSS (19.5 and 21, respectively) and obstructed UDS (79% and 74%, respectively). Both interventions improved voiding and bladder outflow obstruction from baseline, with more patients unobstructed after PAE (63%) compared to medication (28%) (P = 0.03). PAE patients had significantly greater reductions in prostate size (P < 0.001), incomplete emptying (P = 0.002), total IPSS (P = 0.032), Qmax (P = 0.006) and quality of life (P = 0.001). Altered ejaculation, erectile dysfunction and nausea were more common in the medication group.ConclusionProstate artery embolisation was more effective than combined medical therapy at reducing urinary obstruction, decreasing prostate volume and improving LUTS in patients with BPH who had not previously been treated. This is the first randomised control study to compare PAE and combined medical therapy in exclusively treatment‐naïve patients and raises the potential of PAE as an alternative early treatment option for BPH. Further randomised comparative trials are planned to further validate the role of PAE in mitigating obstructive BPH.

Purpose There is an emerging role of the use of Prostate-Specific Membrane Antigen (PSMA) Positron Emission Tomography (PET) in renal cell carcinoma. Herein, we report our experience in use of PSMA PET in recurrent or metastatic renal cell carcinoma (RCC). Methods A retrospective analysis of all patients who underwent PSMA PET for suspected recurrent or de-novo metastatic RCC between 2015 and 2020 at three institutions was performed. The primary outcome was change in management (intensification or de-intensification) following PSMA PET scan. Secondary outcomes included histopathological correlation of PSMA avid sites, comparison of sites of disease on PSMA PET to diagnostic CT and time to systemic treatment. Results

PURPOSE:The objective of this study was to perform an intra-individual dual tracer comparison of Fluorodeoxyglucose (FDG) and Prostate Specific Membrane Antigen (PSMA) computed tomography (CT)/Positron Emission Tomography (PET) against standard of care (SOC) imaging for the characterisation, staging and restaging of renal cell carcinoma (RCC).METHODS:A multicentre retrospective cohort study was performed at 3 major tertiary referral institutions in Brisbane, Australia between 2015 and 2020. All patients who underwent both PSMA and FDG PET/CT following SOC imaging for investigation of RCC were identified. Clinical details, imaging characteristics and histopathology were collected prior to univariate statistical analysis.RESULTS:Eleven patients who underwent dual tracer PET/CT were included. Mean age was 65.5 years (SD 8.8). Most patients were male (64%) with clear cell morphology (91%). The indication for dual tracer PET was staging (36%) and restaging after radical/partial nephrectomy (64%). Primary tumour assessment showed mixed avidity patterns (concordant 40%, discordant favouring PSMA 20%, and FDG 40%). Metastatic disease assessment showed concordant avidity in 6 patients (55%), concordant negative in 3 (27%), and discordant uptake favouring PSMA. PET outperformed SOC imaging for assessment of metastatic disease in 5 patients (45%) and equivalent for the remainder. A change in management was noted in three cases (27%).CONCLUSION:Dual tracer FDG and PSMA PET/CT for assessment of primary and metastatic RCC were mostly concordant. PET imaging outperformed conventional imaging and led to a change in management for 1 in 4 patients. Further studies with larger samples sizes are required to validate these findings and identify characteristics to guide patient selection for selective or dual tracer use.

INTRODUCTION:Venous tumor thrombus (TT) occurs as part of the natural history of renal cell carcinoma (RCC) local progression in a small minority of cases. MRI is currently the most accurate imaging modality for determining TT extent. PSMA PET/CT may improve RCC staging and IVC TT characterization. The objective of this study was to investigate the role of PSMA PET/CT in defining superior extent of TT in RCC and TT IVC tributary vessel spread, with comparative accuracy vs. MRI, to assess suitability for resection and inform preoperative surgical planning.METHODS:Patients who underwent PSMA PET/CT for assessment of renal malignancy with TT from 2015 to 2020 at 3 tertiary hospitals in Brisbane, Australia, were retrospectively identified. TT extent was classified using Mayo Clinic levels and compared according to imaging modality.RESULTS:Fourteen patients were included, all of which were clear cell RCC. Ten patients also underwent MRI, 6 of which were concordant in extent according to MRI and PSMA PET. Discordant extent occurred in 4 patients, of which 2 patients had non-PSMA avid thrombus (Mayo level 0 and level 3 on MRI). Further discordance was seen in a patient with adrenal vein and lumbar vein TT only seen on MRI and PSMA PET/CT, respectively. Finally, discordant extent was seen in another patient with Mayo level 4 TT without lumbar vein involvement on MRI vs. level 3 on PSMA PET/CT with lumbar vein involvement.CONCLUSIONS:PSMA PET/CT can provide additional information about TT extent in RCC which may not be seen on MRI. Additional information from PSMA PET/CT in this setting may assist surgical planning, in addition to detection of metastatic disease.

4540 Background: There is emerging role of the use of PSMA PET in RCC. Herein, we report our experience in use of PSMA PET in recurrent or metastatic RCC in Brisbane, Australia. Methods: Patients (pts) who underwent PSMA PET and conventional diagnostic CT for metastatic or recurrent RCC between 2015 and 2020 at three institutions were identified. Retrospective chart reviews were conducted using standardized collection template. The outcomes included percentage of patients who had a change in management secondary to PSMA PET findings, comparison of metastasis detection for PSMA PET vs. CT, and biopsy histology of PSMA avid sites. Results: 42 PSMA PET were performed in 40 patients. 10 pts (25%) and 30 pts (75%) had PSMA PET in the metastatic disease and recurrent disease setting, respectively. Table 1 highlights demographics. Overall, 12 pts (30%, n=3 metastatic, n=9 recurrent) had a change in management following PSMA PET. In the metastatic disease group, 2 pts (20%) underwent initial systemic therapy (after histological confirmation) due to higher burden of disease shown with PSMA PET than CT, while systemic therapy was changed for 1 pt (10%). In the recurrent disease group, PSMA improved delineation of suspected recurrence (compared to CT) resulting in resection rather than surveillance (n=4; 13%) or change in surgical approach for resection (n=1; 3%). PSMA PET distribution showed more metastatic sites than CT leading to systemic therapy rather than resection of recurrence (n=2; 7%), while absent PSMA activity for suspected recurrence on CT led to surveillance rather than resection (n=2; 7%). PSMA PET detected more sites of metastases compared with conventional scan in 6 pts (60%) with metastatic disease and in 9 pts (30%) with recurrent disease. 26 pts had biopsy of PSMA avid sites. Majority of pts had confirmed recurrence of clear cell renal carcinoma (n= 22; 85%). Other histology included sarcomatoid renal cell carcinoma (n=2; 8%), carcinoid (n=1; 4%), and urothelial cancer (n=1; 4%). In 2 instances, biopsy/resection was performed of a suspected recurrence on CT that was not PSMA avid, and neither showed malignancy. Conclusions: PSMA PET detected more accurately metastatic and recurrent disease, with high pathological concordance, to result in change in management for 30% of patients. Prospective study is warranted to further investigate the utility of PSMA PET scan in advanced RCC.[Table: see text]

In the area of oncology, molecular imaging techniques are becoming increasingly utilised. In neuro-oncology imaging, 18 Fluoro-O-(2) fluoroethyl-L-tyrosine ( 18 F-FET) is one of the molecular tracers used in positron-emission tomography (PET). Here, we investigated the correlation between maximum standard uptake value (SUV) of 18 F-FET PET and histologically determined World Health Organization (WHO) grade in glioma. This was a retrospective review of all 18 F-FET PET studies conducted between August 2014 and August 2019. Review was conducted to identify imaging studies performed on patients who had a glioma with histopathology results from surgical resection or biopsy available. A total of 31 18 F-FET PET studies of histologically confirmed glioma were included. WHO grades ranged from II-IV. A positive correlation between maximum SUV uptake on 18 F-FET PET and WHO grade was observed. There was a correlation identified between WHO glioma grade and maximum SUV on 18 F-FET PET. Further studies are recommended to explore this relationship.

Purpose Lutetium labelled prostate-specific membrane antigen radioligand therapy (Lu-PSMA RLT) has shown pleasing early results in management of high-volume metastatic castration resistant prostate cancer (mCRPC), but its role in the early treatment of men with only lymph node metastasis (LNM) is unknown. The aim was to assess the outcome of Lu-PSMA RLT earlier in the treatment of men with only LNM. Materials and Methods Single institution retrospective review of men with only LNM on staging Ga-PSMA PET PSMA who proceeded with Lu-PSMA RLT. Results There were 17 men with only LNM, including 13 with mCRPC and 3 who were both hormone and chemotherapy naïve. The median PSA was 3.7 (0.46–120 ng/mL). A PSA decline of ≥50% occurred in 10/17 (58.8%), decreasing to <0.2 ng/mL in 35.3% (6/17). The PSA continues to decline or remain stable in 10/17 (58.8%) with a median follow-up of 13 months, and 8/17 (47.1%) have not reached their pre-treatment levels. There were no significant side effects. There was a better PSA response in men without prior chemotherapy (p=0.05). The prostate cancer specific and overall survival is 82.4% (14/17). Conclusions Our results identify improved PSA response to Lu-PSMA RLT in men with only LNM, especially in the chemotherapy naïve cohort, compared to previous series with more advanced mCRPC. These findings provide important proof of principle to aid with planning of future prospective randomized trials evaluating the role of Lu-PSMA RLT earlier in the management of node metastatic prostate cancer, including men naïve of ADT and chemotherapy.

Objectives: Prostate cancer metastasizing to the brain is remarkably uncommon, with the incidence never having been described in the modern setting. The objective of this study was to determine the incidence and imaging pattern of intracranial metastasis from prostate cancer in a large cohort of Australian men with prostate cancer. Material and Methods: Retrospective review was undertaken of imaging reports for all known prostate cancer patients, who underwent an imaging examination inclusive of the brain, between July 1, 2014, and July 1, 2020. Once an intracranial lesion was identified, all available imaging and clinical notes were reviewed. Results: A total of 5644 imaging examinations which included the brain were identified in 4341 prostate cancer patients. The majority (92.1%) of examinations were 68-Gallium-labeled prostate-specific membrane antigen (68Ga-PSMA) positron emission tomography/computed tomography (PET/CT). Eight patients were identified as having an intracranial metastasis from prostate cancer, yielding an incidence of 0.18%. All patients had a Gleason score of 9 (where known), and the majority of patients (5/8) had a non-acinar variant of prostate cancer. At the time of diagnosis of intracranial metastasis, all patients had extensive metastatic disease. Imaging characteristics of the intracranial lesions were highly variable. Conclusion: The incidence of intracranial metastasis in prostate cancer patients has never been well-established. In this study, we determined the incidence as being 0.18%. Given the majority of metastasis constituted unexpected findings on routine restaging 68Ga-PSMA PET/CT, the incidence determined in our study is arguably the most accurate and clinically relevant described to date.

Radioligand therapies, or ‘theranostics’, have an emerging role in patients with metastatic castration‐resistant prostate cancer (mCRPC). Lutetium‐177 (Lu), targeting prostate‐specific membrane antigen (PSMA), has demonstrated promising outcomes including reduced disease progression and improved overall survival. We aim to determine overall survival demonstrated by our LuPSMA patient cohort to date.

FDG-PET and MRI imaging of the pelvis identified a suspicious lesion in a patient with a history of small cell neuroendocrine tumour of the vagina, and after a negative surgical biopsy, a multidisciplinary team meeting decided to proceed with MRGB (magnetic resonance-guided biopsy). The patient remains well and in remission two years after anterior exenteration, with final histology of the lesion determined to be Skene gland adenocarcinoma. MRGB is a novel and effective way to diagnose vaginal lesions.

Pneumoconiosis is an incurable respiratory disease caused by long-term inhalation of respirable dust. Due to small pneumoconiosis incidence and restrictions on sharing of patient data, the number of available pneumoconiosis X-rays is insufficient, which introduces significant challenges for training deep learning models. In this paper, we use both real and synthetic pneumoconiosis radiographs to train a cascaded machine learning framework for the automated detection of pneumoconiosis, including a machine learning based pixel classifier for lung field segmentation, and Cycle-Consistent Adversarial Networks (CycleGAN) for generating abundant lung field images for training, and a Convolutional Neural Network (CNN) based image classier. Experiments are conducted to compare the classification results from several state-of-the-art machine learning models and ours. Our proposed model outperforms the others and achieves an overall classification accuracy of 90.24%, a specificity of 88.46% and an excellent sensitivity of 93.33% for detecting pneumoconiosis.

INTRODUCTION:Coal mine dust lung disease (CMDLD), including the pneumoconioses, dust-related diffuse fibrosis (DDF) and chronic obstructive pulmonary disease (COPD), are occupational lung diseases attributed to respirable coal mine dust. Following the re-identification of CMDLD in Queensland in 2015, we undertook a case series to understand their radiological presentation.METHODS:Chest radiographs and high-resolution computed tomography (HRCT) were retrospectively reviewed for 79 male individuals diagnosed by a respiratory physician with a CMDLD since 2015. Radiological findings were characterised as per the International Labour Office Classification System (ILO system) and the International Classification of HRCT for Occupational and Environmental Respiratory Diseases (ICOERD).RESULTS:Subjects with pneumoconiosis (n = 56) demonstrated widespread opacities with bilateral upper zone predominance. The majority of the lung was impacted, with 72% and 79% of zones demonstrating opacities on chest radiograph and HRCT, respectively. Most pneumoconiosis subjects (71%) demonstrated ILO category 1 disease, while 29% had advanced disease (ILO grades ≥ 2/1). A high proportion (81%) of pneumoconiosis subjects demonstrated at least one radiological feature associated with exposure to respirable crystalline silica (RCS). DDF subjects (n = 5) had radiologically severe disease (mean ILO 2/1) with lower zone-predominant irregular opacities. Widespread emphysema, with no zone dominance, was the key radiological feature in those with COPD (n = 18).CONCLUSION:Radiological findings of particular interest included the high burden of opacities observed and the presence of RCS-associated features in the majority of subjects. Radiologists are at the front line in occupational lung disease screening/diagnosis and must be aware of the imaging spectrum.

ObjectivesTo determine the proportion of solitary rib lesions on pre‐treatment 68Gallium‐labelled prostate‐specific membrane antigen (PSMA)/computed tomography (CT) scans in men with prostate cancer that are malignant and examine any predictive factors.Patients and methodsThis retrospective single tertiary referral institution cohort study of men reviewed the results of 68Ga‐PSMA‐11 positron emission tomography (PET)/CT scans performed for primary staging prior to treatment of prostate cancer from July 2014 to September 2019. Men with PSMA uptake outside the prostate in only the rib lesion were included. A solitary rib lesion was considered to be malignant if it increased in size on follow‐up imaging. A lesion was considered benign if the prostate‐specific antigen (PSA) level remained <0.1 µg/L following a radical prostatectomy (RP), <2 µg/L above nadir following radiotherapy (RT) as per the Phoenix criteria, histology was benign on rib biopsy, or follow‐up imaging showed no growth of the rib lesion. If a lesion did not meet these criteria it was considered indeterminate.ResultsA total of 62 men had PSMA uptake in a solitary rib lesion; 54 went on to have RPs and eight underwent RT. In all, 61 of the men (98.4%) met the criteria for a benign rib lesion. Only one man had a false‐negative malignant lesion. This man had a rib lesion with a low maximum standardised uptake value (SUVmax) of 2.21 reported as benign, but the postoperative PSA level was 0.67 µg/L and the rib lesion progressed on follow‐up imaging, with development of widespread metastases. Of the benign rib lesions, there were four false positives reported as possible metastases. Three had percutaneous rib biopsies, two of which came back with benign histology and one was indeterminate. The indeterminate biopsy patient had a RP and his postoperative PSA level was <0.1 µg/L. A total of 43 (69.4%) men with benign rib lesions had a SUVmax greater than the SUVmax of the malignant lesion.ConclusionTo our knowledge, this is the first cohort study of men with PSMA‐avid solitary rib lesions on pre‐treatment 68Ga‐PSMA PET/CT staging scans for prostate cancer. Our results indicate that the vast majority of these lesions have low‐intensity uptake and are benign. Intervention to confirm this is not usually required.

BACKGROUND:Prostate cancer commonly metastasises to bone and regional lymphatics and more rarely to locations such as the brain, skin and penis. Gallium-68 prostate-specific membrane antigen (68 Ga-PSMA) positron emission tomography/computed tomography (PET/CT) has widely become the routine imaging modality for prostate cancer staging and re-staging in Australia. The aim of this study was to retrospectively review all 68 Ga-PSMA PET/CT examinations performed to date at our institution to determine the frequency of penile metastases.METHODS:A total of 4860 68 Ga-PSMA PET/CT examinations were performed between 16/07/2014 and 31/10/2019. Radiology reports for each examination were filtered to identify those with the words 'penis' or 'penile'. Once identified, relevant reports and images were individually reviewed to confirm the presence of a PSMA-avid penile lesion.RESULTS:The incidence of penile metastasis of prostate cancer observed in this study was 0.1% with six examinations identified as having PSMA-avid penile lesions in five prostate cancer patients (age range: 71-88 years). The patients had a 1-8 year history of prostate cancer with varying severity of disease. Appearance of PSMA-avidity varied between single focal lesion, multiple focal lesions and diffuse lesion.CONCLUSIONS:An incidence of 0.1% in our study confirms the rarity of penile metastases of prostate cancer. Although rare, identification of prostate cancer penile metastases is important for appropriate treatment management and symptom-relief.

Staging/restaging of prostate cancer utilizing Gallium-68 (68Ga) prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in combination with an intravenous urogram allows improved discrimination between radiotracer activity in the renal tract and small pelvic nodes or local recurrences. Within this pictorial essay, we describe the imaging protocol utilized at our institution and present cases which demonstrate the utility of this combined imaging approach.