Antonio Carlos Westphalen

Active surveillance (AS) is an established management strategy for men with low-risk and some favorable intermediate-risk prostate cancer. Multiparametric MRI (MRI) plays an increasingly important role in AS, contributing to initial risk stratification, confirmatory evaluation, and longitudinal monitoring. However, comparing baseline and follow-up MR images is challenging because acquisition varies, readers differ, and imaging alone has limited ability to define clinically meaningful progression. The Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system was developed to standardize the assessment of interval change on serial prostate MRI. PRECISE provides a structured framework for categorizing radiologic regression, stability, and progression, thereby addressing a key limitation of Prostate Imaging – Reporting and Data System (PI-RADS), which was designed for lesion detection rather than longitudinal assessment. PRECISE version 2 further refines definitions and introduces clearer categories, including separation of stable visible and stable non-visible disease and recognition of non-diagnostic examinations. Available evidence suggests that PRECISE performs best as a rule-out tool, with consistently high negative predictive value for clinically significant progression, while radiologic progression demonstrates more limited positive predictive value for histopathologic upgrading. Although PRECISE reduces subjective interpretation through structured scoring, its application remains affected by variability in MRI quality and heterogeneity in AS protocols. To mitigate these limitations, radiologists should incorporate prostate-specific antigen kinetics, biopsy results, and clinical context into their interpretation of serial MRI. In this review, we provide a practical, radiologist-focused overview of PRECISE, summarize its evolution and evidence base, and illustrate its application in clinical practice. We also discuss key limitations, common pitfalls, and the importance of MRI quality and standardization in improving reproducibility. PRECISE represents an important step toward standardized longitudinal assessment in prostate cancer AS and supports more consistent, evidence-based multidisciplinary decision-making.

The PRECISE version 2 criteria include standardized MRI protocols for active surveillance in patients with prostate cancer to compare baseline and follow-up examinations, evaluate radiologic change, and assign a score of 1–5 to indicate radiologic regression, stability (for visible and nonvisible disease), or progression, thereby assisting with clinical treatment decisions.

ChatGPT-4 Turbo and Llama 3 accurately assigned PI-RADS version 2.1 scores to structured prostate MRI reports using zero-shot prompting, demonstrating high agreement with abdominal radiologists.

To assess the diagnostic value of the delayed excretory phase in computed tomography urography (CTU) for detecting renal and urinary tract abnormalities and its impact on readers' confidence in patients with hematuria, given concerns about radiation exposure, cost, and limited added benefit. This IRB-approved, HIPAA-compliant retrospective cross-sectional study included 489 CTU exams performed at a quaternary center between 2012 and 2023. Each scan included non-contrast, nephrographic, and delayed phases. Six radiologists with varying experience independently reviewed exams in two sessions: Session 1 (without delayed phase) and Session 2 (with delayed phase), separated by a minimum three-week washout period. Abnormalities were assessed using standardized criteria; diagnostic confidence was rated (0-100%). Analyses included McNemar's test, mixed-effects logistic regressions, and Wilcoxon signed-rank tests; p < 0.05 was statistically significant. No significant differences were found in detecting most abnormalities between sessions. Cystic renal masses were more often detected in Session 1 (p = 0.05, OR = 1.40, 95% CI: 0.99-1.98). Detection increased in Session 2 for renal (p = 0.002, OR = 0.35) and ureteral congenital anomalies (p = 0.004, OR = 0.30). Intermediate-experience readers had lower odds of detecting renal (OR = 0.09) and cystic masses (OR = 0.08); experienced readers missed more ureteral anomalies (OR = 0.21). Delayed imaging did not improve overall detection or reader performance. Diagnostic confidence was lower in Session 2 (p < 0.001), particularly among less experienced readers. The delayed excretory phase in CTU modestly improved detection of congenital anomalies but did not enhance identification of ureteral or bladder lesions or diagnostic confidence. Selective use may reduce radiation exposure without compromising diagnostic performance.

Blood pressure measurement is important in monitoring hypertension. However, blood pressure does not provide much information about renal condition in treated hypertension. This study aimed to evaluate renal oxygenation in hypertensive patients using T2* mapping. Subgroup analysis explored whether R2* values can guide adjustments in antihypertensive treatment. A total of 140 consecutive subjects were recruited: 87 hypertensive subjects and 53 normotensive subjects. Hypertensive subjects were classified into non-medication (non-med), angiotensin II receptor blocker (ARB), and non-ARB-treated groups. Each group was divided into good and poor control subgroups based on blood pressure at enrollment. T2* mapping was utilized to assess renal cortical and medullary R2* values. After a 2-year follow-up, subjects were categorized into stable and unstable based on the need for treatment modifications. The unstable subgroup had higher medullary R2* values than the stable subgroup in all followed patients (p < 0.05). Additionally, the unstable merged non-med with ARB subgroup had higher medullary R2* values overall (p < 0.05) and within the good control subgroup (p < 0.05). Patients with stable hypertension, especially those with good control managed through lifestyle modifications or ARBs, exhibited lower renal medullary R2* values, suggesting higher renal oxygenation.

Objective: To determine the proportion of men with completely negative multiparametric magnetic resonance imaging (MRI) scans and which individual sequence-T2-weighted imaging (T2WI) or diffusion-weighted imaging (DWI)-best predicts an overall negative examination result. Materials and Methods: This was a single-center retrospective study evaluating 492 MRI scans compliant with Prostate Imaging Reporting and Data System (PI-RADS), version 2.1. Radiology reports described the absence of lesions or suspicious lesions with PI-RADS scores of 3-5, signifying positive T2WI or DWI results. Positivity on a dynamic contrast-enhanced (DCE) study was determined by early or simultaneous focal enhancement consistent with lesions on T2WI or DWI. All scans reported as negative were prospectively reviewed to ensure that each sequence truly met the criteria for negativity according to the PI-RADS guidelines. Descriptive statistics were employed to summarize the data, and the chi-square test was employed to assess the relationship between a negative T2WI result and a negative DWI/DCE result, as well as that between a negative DWI result and a negative DWI/DCE result, with logistic regression models identifying predictors of such combined results. Results: Among the patients evaluated, approximately one-third of those with suspected prostate cancer and 10% of those with known cancer could have concluded their examination after a single negative sequence. A negative T2WI result predicted negative DWI/DCE findings in 62.4% of scans (95% CI: 55.3-68.9), with an odds ratio of 245.3 (p < 0.001). Similarly, a negative DWI result predicted negative T2WI/DCE findings in 88.9% of scans (95% CI: 83.1-92.7) with an odds ratio of 76.4 (p < 0.001). These associations remained robust after adjustment for age, prostate-specific antigen level, prostate-specific antigen density, cancer status, and radiologist. Conclusion: Findings from T2WI or DWI may serve as preliminary indicators for the subsequent diagnostic yield of other sequences, with DWI appearing to hold a slight advantage. Although the accuracy of this approach is not yet sufficient for clinical implementation, these results are promising and merit further investigation.