Alessandro Franceschelli

11C-Choline Positron Emission Tomography/Computerized Tomography for Preoperative Lymph-Node Staging in Intermediate-Risk and High-Risk Prostate Cancer: Comparison with Clinical Staging Nomograms

BACKGROUND Conventional imaging (CI) techniques are inadequate for lymph node (LN) staging in prostate cancer (PCa). OBJECTIVES To assess the accuracy of (11)C-Choline positron emission tomography/computerized tomography (PET/CT) for LN staging in intermediate-risk and high-risk PCa and to compare it with two currently used nomograms. DESIGN, SETTING, AND PARTICIPANTS From January 2007 to September 2007, 57 PCa patients at intermediate risk (n=27) or high risk (n=30) were enrolled at two academic centres. All patients underwent preoperative PET/CT and radical prostatectomy with extended pelvic LN dissection (PLND). Risk of LN metastasis (LNM) was assessed using available nomograms. MEASUREMENTS Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and number of correctly recognized cases for LNM detection at PET/CT were assessed. The accuracy of PET/CT for LNM detection was compared with the accuracy of nomograms for LNM prediction by using receiver operating characteristic (ROC) analysis. RESULTS AND LIMITATIONS Fifteen patients (26%) had LNMs, and a total of 41 LNMs were identified. On a patient analysis, sensitivity, specificity, PPV, NPV, and number of correctly recognized cases at PET/CT were 60.0%, 97.6%, 90.0%, 87.2%, and 87.7% while, on node analysis, these numbers were 41.4%, 99.8%, 94.4%, 97.2%, and 97.1%. The mean diameter (in mm) of the metastatic deposit of true-positive LNs was significantly higher than that of false-negative LNs (9.2 vs 4.2; p=0.001). PET/CT showed higher specificity and accuracy than the nomograms; however, in pairwise comparison, the areas under the curve (AUCs) were not statistically different (all p values >0.05). CONCLUSIONS In patients with intermediate-risk and high-risk PCa, (11)C-Choline PET/CT has quite a low sensitivity for LNM detection but performed better than clinical nomograms, with equal sensitivity and better specificity.

Influence of Trigger PSA and PSA Kinetics on 11C-Choline PET/CT Detection Rate in Patients with Biochemical Relapse After Radical Prostatectomy

The purpose of this study was to investigate the effect of total prostate-specific antigen (PSA) at the time of 11C-choline PET/CT (trigger PSA), PSA velocity (PSAvel), and PSA doubling time (PSAdt) on 11C-choline PET/CT detection rate in patients treated with radical prostatectomy for prostate cancer, who showed biochemical failure during follow-up. Methods: A total of 190 patients treated with radical prostatectomy for prostate cancer who showed an increase in PSA (mean, 4.2; median, 2.1; range, 0.2–25.4 ng/mL) were retrospectively enrolled. All patients were studied with 11C-choline PET/CT. Patients were grouped according to trigger PSA (PSA ≤ 1 ng/mL, 1 < PSA ≤ 2 ng/mL, 2 < PSA ≤ 5 ng/mL, and PSA > 5 ng/mL). In 106 patients, data were available for calculation of PSAvel and PSAdt. Logistic regression analysis was used to determine whether there was a relationship between PSA levels and PSA kinetics and the rate of detection of relapse using PET. Results: 11C-choline PET/CT detected disease relapse in 74 of 190 patients (38.9%). The detection rate of 11C-choline PET/CT was 19%, 25%, 41%, and 67% in the 4 subgroups—PSA ≤ 1 ng/mL (51 patients), 1 < PSA ≤ 2 ng/mL (39 patients), 2 < PSA ≤ 5 ng/mL (51 patients), and PSA > 5 ng/mL (49 patients)—respectively. Trigger PSA values were statistically different between PET-positive patients (median PSA, 4.0 ng/mL) and PET-negative patients (median PSA, 1.4 ng/mL) (P = 0.0001). Receiver-operating-characteristic analysis showed an optimal cutoff point for trigger PSA of 2.43 ng/mL (area under the curve, 0.76). In 106 patients, PSAdt and PSAvel values were statistically different between patients with PET-positive and -negative scan findings (P = 0.04 and P = 0.03). The 11C-choline PET/CT detection rate was 12%, 34%, 42%, and 70%, respectively, in patients with PSAvel < 1 ng/mL/y (33 patients), 1 < PSAvel ≤ 2 ng/mL/y (26 patients), 2 < PSAvel ≤ 5 ng/mL/y (19 patients), and PSAvel > 5 ng/mL/y (28 patients). The 11C-choline PET/CT detection rate was 20%, 40%, 48%, and 60%, respectively, in patients with PSAdt > 6 mo (45 patients), 4 < PSAdt ≤ 6 mo (20 patients), 2 < PSAdt ≤ 4 mo (31 patients), and PSAdt ≤ 2 mo (10 patients). There was no statistical difference between PET-positive and -negative scan detection rates according to the Gleason score, pT and N status, patient age, or duration between surgery and biochemical relapse. Trigger PSA and PSAvel were found to be independent predictive factors for a PET-positive result (P = 0.002; P = 0.04) and PSAdt was found to be an independent factor only in patients with trigger PSA less than 2 ng/mL (P = 0.05) using multivariate analysis. Conclusion: The 11C-choline PET/CT detection rate is influenced by trigger PSA, PSAdt, and PSAvel. This finding could be used to improve the selection of patients for scanning by reducing the number of false-negative scans and increasing the detection rate of disease in patients with early relapse and potentially curative disease.

Accuracy of MRI/MRSI-based transrectal ultrasound biopsy in peripheral and transition zones of the prostate gland in patients with prior negative biopsy

The purpose of the study was to evaluate the accuracy of transrectal ultrasound biopsy (TRUS‐biopsy) performed on regions with abnormal MRI and/or MRSI for both the transition (TZ) and the peripheral (PZ) zones in patients with suspected prostate cancer with prior negative biopsy, and to analyze the relationship between MRSI and histopathological findings. MRI and MRSI were performed in 54 patients (mean age: 63.9 years, mean PSA value: 11.4 ng/mL) and the ability of MRI/MRSI‐directed TRUS biopsy was evaluated. A three‐point score system was used for both techniques to distinguish healthy from malignant regions. Descriptive statistics and ROC analyses were performed to evaluate the accuracy and the best cut‐off in the three‐point score system. Twenty‐two out of 54 patients presented cancer at MRI/MRSI‐directed TRUS biopsy, nine presented cancer only in PZ, eight both in PZ and TZ, and five exclusively in TZ. On a patient basis the highest accuracy was obtained by assigning malignancy on a positive finding with MRSI and MRI even though it was not significantly greater than that obtained using MRI alone (area under the ROC curve, AUC: 0.723 vs 0.676). On a regional (n = 648) basis the best accuracy was also obtained by considering positive both MRSI and MRI for PZ (0.768) and TZ (0.822). MRSI was false positive in 11.9% of the regions. Twenty‐eight percent of cores with prostatitis were false positive findings on MRSI, whereas only 2.7% of benign prostatic hyperplasia was false positive. In conclusion, the accuracy of MRI/MRSI‐directed biopsies in localization of prostate cancer is good in patient (0.723) and region analyses (0.768). The combination of both MRI and MRSI results makes TRUS‐biopsy more accurate, particularly in the TZ (0.822) for patients with prior negative biopsies. Histopathological analysis showed that the main limitation of MRSI is the percentage of false positive findings due to prostatitis. Copyright

Can Testis-Sparing Surgery for Small Testicular Masses Be Considered a Valid Alternative to Radical Orchiectomy? A Prospective Single-Center Study

BACKGROUND The aim of this study was to evaluate the incidence of malignancy in small testicular masses (STMs) treated with testis-sparing surgery (TSS) with intraoperative frozen section analysis and to assess the safety of this surgical procedure. PATIENTS AND METHODS From January 2009 to January 2013, 15 consecutive patients underwent TSS for STMs in a third-referral academic institution. Every patient was preoperatively evaluated with clinical examination and scrotal ultrasonography (US) performed by the same radiologist. Tumor markers were assessed in all cases. All the procedures were performed through inguinal access; the small mass was identified by straight palpation of the testis or with intraoperative ultrasonography (IUS). Frozen-section examination (FSE) was performed in all patients in association with multiple biopsies of the surrounding tissue. Follow-up was carried out in all patients with an ultrasonographic exploration at 6 and 12 months. RESULTS Preoperative tumor markers were normal in all patients. The mean operative time was 90 ± 31 minutes. The warm ischemia time was 18 ± 3 minutes. The mean size on US was 9.5 ± 4.4 mm. FSE results were confirmed by the final pathologic analysis in 14 patients. At final pathologic analysis, 6 patients (40%) were found not to have tumors, another 7 patients (46.7%) had benign neoplasms, and malignant tumor was found in only 2 patients (13.3%). There was no disease recurrence after a mean follow-up of 19.2 ± 11.5 months. CONCLUSION Our experience shows that TSS performed for STMs may represent a safe procedure with optimal results in terms of functional and oncologic end points.

Positron-emission tomography in imaging and staging prostate cancer

With increasing application of positron-emission tomography (PET) imaging, familiarity with the applications of PET in genitourinary oncology, especially prostate-cancer (PCa) imaging, becomes important. PET studies provide functional information using radiolabeled tracers, with fluoro-dexoxy-glucose (FDG) being the most commonly used. Nevertheless FDG has limitations for evaluation of PCa patients and therefore alternative tracers are being investigated. To date, the best results have been obtained with 11C-choline and 11C-acetate PET, which seem to demonstrate similar values in this field. We review the current role of PET in PCa patients based on data published in the literature as well as our own experience. Most studies of PET imaging of PCa address three goals: a) detecting primary PCa; b) staging PCa; and c) assessing PCa recurrence. From available results, routine clinical use of 11C-choline PET cannot be recommended for detecting and staging primary PCa. At present, the only clinical indication for imaging PCa with 11C-choline-PET is evaluation of suspected recurrence after treatment.

Should We Perform Imaging-Guided Lymph Node Dissection in Patients with Lymphatic Recurrence of Prostate Cancer after Radical Prostatectomy?

Nearly 30–40% of patients who undergo radical prostatectomy present with biochemical evidence of cancer recurrence and, after a mean time of 3 yr, 10–30% of them will develop clinical recurrence [1]. The diagnostic work-up in the presence of biochemical relapse should be conducted with a view to distinguishing between the probability of local failure only or of distant failure, and this is essentially guided by the kinetics of the prostatespecific antigen (PSA) values and the initial pathology. Unfortunately, traditional imaging techniques are neither adequately sensitive nor very specific for both the early identification of the local recurrence (which is the sole tumor recurrence amenable to a ‘‘curative treatment’’ with salvage radiotherapy) and the simultaneous exclusion of the distant recurrence. Furthermore, when a local recurrence seems to be excluded and a systemic relapse is presumed, imaging techniques such as bone scan or computed tomography (CT) are of no additional diagnostic value unless the PSA serum level is >20 ng/ml, and generally, these patients undergo ‘‘palliative’’ treatment with hormonal deprivation. At the present time, there is no therapy that can be considered curative for such patients [2]. Thanks to more recent metabolic imaging techniques—in particular C/F-choline and C-acetate positron emission tomography (PET), which combine morphological and functional information—it is now possible to identify the site of

Computerized tomography virtual endoscopy in evaluation of upper urinary tract tumors: initial experience

PurposeTo assess the usefulness of CT virtual endoscopy (VE) as an integration of CT-urography, for the detection of upper urinary tract tumor in patients with hematuria.Materials and methodsFourteen patients with hematuria and high risk of transitional cell carcinoma of the upper urinary tract underwent urinary cytology, ultrasonography, excretory urography, cystoscopy, CT-urography with VE, and optical ureteroscopy. The CT urograms and VE were correlated with the pathological findings of surgical specimen (6/14) and cytological examination of ureteroscopy biopsy (8/14).ResultsVE revealed three renal pelvic and one ureteral tumors, not producing further information did not detected at CT-urography. In two patients VE showed findings strongly indicative of malignancies, not noticed at CT-urography: ureteroscopic biopsy revealed an advanced dysplastic lesion and a malignancy, confirmed at surgery. In one patient VE was questionable (narrowing of the distal ureter) and ureteroscopic biopsy revealed an inflammation. Finally, VE diagnosed a fibrosis of the lumbar ureteral tract, confirmed at ureteroscopic biopsy. In other six patients, VE and ureteroscopy did not find abnormalities.ConclusionVE should be useful as an integration of CT-urography for a complete evaluation of the upper urinary tract in patients with suspected tumor, limiting the need for fiberoptic ureteroscopic examination.

Sex-related penile fracture with complete urethral rupture: A case report and review of the literature

OBJECTIVE To present the management of a patient with partial disruption of both cavernosal bodies and complete urethral rupture and to propose a non-systematic review of literature about complete urethral rupture. MATERIAL AND METHOD - CASE REPORT: A 46 years old man presented to our emergency department after a blunt injury of the penis during sexual intercourse. On physical examination there was subcutaneous hematoma extending over the proximal penile shaft with a dorsal-left sided deviation of the penis and urethral bleeding. Ultrasound investigation showed an hematoma in the ventral shaft of the penis with a discontinuity of the tunica albuginea of the right cavernosal corporum. The patient underwent immediate emergency surgery consisted on evacuation of the hematoma, reparation the partial defect of both two cavernosal bodies and end to end suture of the urethra that resulted completely disrupted. RESULTS The urethral catheter was removed at the 12-th postoperative day without voiding symptoms after a retrograde urethrography. 6 months postoperatively the patients was evaluated with uroflowmetry demonstrating a max flow rate of 22 ml/s and optimal functional outcomes evaluated with validated questionnaires. 8 months after surgery the patients was evaluated by dynamic magnetic resonance (MRI) of the penis showing only a little curvature on the left side of the penile shaft. CONCLUSION Penile fracture is an extremely uncommon urologic injury with approximately 1331 reported cases in the literature till the years 2001. To best of our knowledge from 2001 up today, 1839 more cases have been reported, only in 159 of them anterior urethral rupture was associated and in only 22 cases a complete urethral rupture was described. In our opinion, in order to prevent long term complications, in case of clinical suspicion of penile fracture, especially if it is associated to urethral disruption, emergency surgery should be the first choice of treatment.

11C-CHOLINE-POSITRON EMISSION TOMOGRAPHY/ COMPUTERISED TOMOGRAPHY FOR PREOPERATIVE LYMPH- NODE STAGING IN INTERMEDIATE-RISK AND HIGH-RISK PROSTATE CANCER: COMPARISON WITH CLINICAL STAGING NOMOGRAMS

Background: Conventional imaging (CI) techniques are inadequate for lymph node (LN) staging in prostate cancer (PCa). Objectives: To assess the accuracy of 11 C-Choline positron emission tomography/computerized tomography (PET/CT) for LN staging in intermediate-risk and high-risk PCa and to compare it with two currently used nomograms. Design, Setting, and Participants: From January 2007 to September 2007, 57 PCa patients at intermediate risk (n = 27) or high risk (n = 30) were enrolled at two academic centres. All patients underwent preoperative PET/CT and radical prostatectomy with extended pelvic LN dissection (PLND). Risk of LN metastasis (LNM) was assessed using available nomograms. Measurements: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and number of correctly recognized cases for LNM detection at PET/CT were assessed. The accuracy of PET/CT for LNM detection was compared with the accuracy of nomograms for LNM prediction by using receiver operating characteristic (ROC) analysis. Results and Limitations: Fifteenpatients(26%)hadLNMs,andatotalof41LNMswereidentified.On a patient analysis, sensitivity, specificity, PPV, NPV, and number of correctly recognized cases at PET/CT were 60.0%, 97.6%, 90.0%, 87.2%, and 87.7% while, on node analysis, these numbers were 41.4%, 99.8%, 94.4%, 97.2%, and 97.1%. The mean diameter (in mm) of the metastatic deposit of true-positiveLNswassignificantlyhigherthanthatoffalse-negativeLNs(9.2vs4.2;p = 0.001).PET/ CT showed higher specificity and accuracy than the nomograms; however, in pairwise comparison, the areas under the curve (AUCs) were not statistically different (all p values >0.05). Conclusions: In patients with intermediate-risk and high-risk PCa, 11 C-Choline PET/CT has quite a low sensitivity for LNM detection but performed better than clinical nomograms, with equal sensitivity and better specificity.

PPTLBA-01 QUALITY OF LIFE AFTER PENILE PROSTHESIS IMPLANTATION – 1 YEAR FOLLOW-UP DATA OF THE ITALIAN PROSPECTIVE REGISTRY INSIST-ED

Paolo Capogrosso*, Giovanni Alei, Gabriele Antonini, Antonio Avolio, Antonio Barbieri, Carlo Bettocchi, Marco Bitelli, Francesco Boezio, Masssomo Capone, Enrico Caraceni, Maurizio Carrino, Carlo Ceruti, Sandro Ciampalini, Fulvio Colombo, Enrico Conti, Antonio Corvasce, Giuseppe Dachille, Diego Pozza, Stefano Fiordelise, Alessandro Franceschelli, Giulio Garaffa, Nicola Ghidini, FrancoGiorgio, Emilio Italiano, Giuseppe La Pera, Antonino Lagan a, Giovanni Liguori, Lilia Utizi, Matteo Matera, Nicola Mondaini, Alessandro Natali, Carlo Negro, Fabrizio Palumbo, Matteo Paradiso, Edoardo Pescatori, MassimoPolito,GaiaPolloni, AndreaSalonia,MauroSilvani, AldoTamai, Massimiliano Timpano, Francesco Varvello, Patrizio Vicini, Antonio Vitarelli, Antonio Palmieri, Federico Deh o, Milan, Italy