Charles F. McKiel

Transurethral Microwave Thermotherapy for Management of Benign Prostatic Hyperplasia: Results of the United States Prostatron Cooperative Study

The primary objective of the study was to determine the safety and efficacy of transurethral microwave thermotherapy for the treatment of symptomatic benign prostatic hyperplasia. From March to August 1991, 150 patients were entered into a multi-site study and treated with transurethral microwave thermotherapy under a Food and Drug Administration approved protocol. Only patients with symmetrical trilobar or bilobar prostatic hypertrophy, peak flow rate of less than 15 cc per second (on 2 voided volumes of 150 cc or greater) and a total Madsen symptom score of more than 8 were treated. Transurethral microwave thermotherapy was performed with a 20F catheter and 1,296 MHz. microwave antenna for 60 minutes. The mean power achieved for this single session was 32.1 watts, with a mean power at maximum urethral temperature of 41.1 watts. Mean urethral temperature was 44.3C and the mean rectal temperature was 42.2C. The rectal and urethral temperatures were continuously monitored. Mean peak urinary flow rates, Madsen symptom score, post-void residual volume and improvement in motivating symptom to seek treatment were measured at 6 weeks, and 3, 6 and 12 months. Mean peak urinary flow rates improved 33% at 12 months (p < 0.0001). Overall, the mean Madsen symptom score improved 61% (p < 0.0001). The obstructive score and the irritative score improved 67% and 43%, respectively. Of 17 patients 12 (71%) reported improvement in weak stream when that was the motivating symptom to seek treatment. Of 28 men 18 (64%) reported improvement in nocturia, while 11 of 30 (37%) reported improvement in daytime frequency and 12 of 17 (71%) reported improvement in urgency. There was no statistically significant difference in post-void residual volume at 12 months from baseline. The treatment was well tolerated by all patients, and side effects were considered mild and transitory. Our study demonstrates the safety, effectiveness, patient tolerability and durability of transurethral microwave thermotherapy.

Percutaneous Cryoablation of the Prostate: Preliminary Results After 95 Procedures

PURPOSE We examined the role of percutaneous cryoablation of the prostate in the treatment of prostate cancer. MATERIALS AND METHODS We performed 95 percutaneous cryoablations of the prostate on 87 patients with prostate cancer. Of the patients 6 had positive lymph nodes preoperatively, radiation failed in 9 and 9 began postoperative hormonal therapy because of treatment failure. Mean patient age, prostate specific antigen (PSA) level (ng./ml.) and Gleason score were 65.4, 12.60 and 6.03, respectively. Median followup was 12 months (mean 9.3, range 1 to 24). In 49 of the 87 patients (56%) the lymph nodes were evaluated before cryoablation based on the treatment protocol. RESULTS Median PSA level at 12 months was 0.55 ng./ml. (mean 1.73) with a 17% positive biopsy rate at 3 months. When the positive lymph node, radiation failure and postoperative hormonal therapy groups were removed from analysis, the median PSA level was 0.80 ng./ml. (mean 1.86) with a 5% positive biopsy rate. Of the patients in the radiation failure group 37% had a positive biopsy at 3 months. Cases were classified according to stage, grade and PSA level, and the biopsy results were presented. The complications of percutaneous cryoablation of the prostate were reviewed. CONCLUSIONS The low percentage of positive biopsies is encouraging but the significance of the persistent PSA levels remains uncertain.

Renal Medullary Carcinoma in Patients with Sickle Cell Trait

Renal medullary carcinoma has recently been described as an aggressive neoplasm affecting young African Americans with sickle cell disease or sickle cell trait. We report the presentation, treatment, and outcome in 3 patients with renal medullary carcinoma along with a description of the unsuccessful treatment attempts. A brief discussion and review of the literature is included.

Acquired Immunodeficiency Syndrome Presenting as Testicular Lymphoma

A case of a rapidly expanding testicular mass in a 38-year-old homosexual whose human immunodeficiency virus status was unknown is presented. The mass proved to be lymphoma and serological testing for human immunodeficiency virus was positive. To our knowledge this is the second reported case of acquired immunodeficiency syndrome presenting as a testicular lymphoma.

Tumor Infiltrating Lymphocytes: The Effect of Bacillus Calmette Guerin on Helper/Suppressor-T Cell Ratios of Treated and Untreated Tumors

Copenhagen X Fischer rats bearing single and bilateral Dunning R3327 AT-3 tumors were either treated or not treated at a single site with bacillus Calmette Guerin (BCG). One week later tumors were removed, tumor infiltrating lymphocytes (TILs) isolated, and then characterized for total-T, helper-T and suppressor-T cell subsets utilizing monoclonal antibodies. The purpose was to determine the effect of BCG on TILs in treated as well as untreated tumors. In summary: 1) BCG treatment significantly alters TIL distributions at both injected and noninjected sites; 2) a noninjected contralateral tumor compromises the effectiveness of BCG therapy at the suppressor T cell level; 3) contralateral tumors, whether inoculated or not, have similar TIL distributions.

Responsiveness of lymphocytes to soluble extracts of prostatic tumors and abrogation by serum-blocking factor(s)

Preliminary evidence is presented suggestive of antitumor immunity, cross reactive with allogeneic extracts from tumors of the same type, and serum-blocking factor(s), which appear to be specific to autologous tumor only, in patients with prostatic cancer employing the method of leukocyte adherence inhibition.

Central zone lesions on magnetic resonance imaging: Should we be concerned?

INTRODUCTION AND OBJECTIVE The Prostate Imaging Reporting and Data System (PI-RADS) score was developed to evaluate lesions in the peripheral and transition zone on multiparametric magnetic resonance imaging (mpMRI) of the prostate. We aim to determine if the PI-RADS scoring system can be used to evaluate central zone lesions on mpMRI. MATERIALS AND METHODS A retrospective review of 73 patients who underwent mpMRI/ultrasound (US) fusion-guided biopsy of 143 suspicious lesions between February 2014 and October 2015 was performed. All patients underwent a 3T mpMRI. Indications for mpMRI included an abnormal digital rectal examination, PSA velocity >0.75ng/dl/y, and patients on active surveillance. The mpMRI sequence involved T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast enhancement. Using 3-dimensional model software (Invivo Corporation, Gainesville, FL, USA), a minimum of 3 magnetic resonance imaging (MRI)/US fusion-guided biopsy samples were taken from each prostate lesion seen on mpMRI irrespective of PI-RADS score, using local anesthesia in an outpatient clinic setting. RESULTS A total of 73 patients underwent MRI/US fusion-guided biopsy of 85 peripheral zone lesions, 31 transitional zone lesions, and 27 central zone lesions. Only 2 (7%) of central zone lesions were positive for prostate cancer. Both patients had lesions which were graded as PI-RADS 3. Both the patients had multifocal lesions that encompassed≥50% of the central and transition zones on the sagittal view MRI images. Both patients previously had transrectal US-guided biopsy of the prostate which was negative for cancer. Both patients underwent a robotic-assisted laparoscopic prostatectomy, each revealing high-grade cancer. CONCLUSIONS Lesions involving only the central gland/zone seen on MRI are less concerning for malignancy and should not be given equal weight as peripheral zone lesions. In this series, no lesions involving solely the central gland/zone, regardless of PI-RADS score, was positive for malignancy on MRI/US fusion-guided biopsy. Consideration of a modified PI-RADS scoring system should be given to help identify central zone lesions with malignant potential.

GM-CSF restoration of a differentiated (growth factor-regulated) phenotype in an anaplastic tumor

SummaryGM-CSF (granulocyte-macrophage-derived colony-stimulating factor) is a differentiation agent that stimulates bone marrow activity in patients receiving chemotherapy. GM-CSF (1 μg/ml daily for 10 days), administered intralesionally, was evaluated to determine whether it would restore a more differentiated phenotype to an anaplastic, rapidly growing, hormone-independent variant (R3327 MAT-LyLu) of the Dunning prostatic adenocarcinoma. Immunohistology was used to quantitate the expression of epithelial growth factor receptors (rEGF) and the tissue testosterone content. GM-CSF therapy significantly (P<0.05) restored rEGF expression and tissue testosterone to levels associated with better differentiated, slower growing, androgen-dependent Dunning variants (R3327 H and G). GM-CSF may have a role in treatment of prostatic cancers by promoting androgen and epithelial growth factor regulation.

Role of transurethral resection of the prostate in hematogenously disseminated metastasis.

Dissemination of tumor cells by vascular channels seems to be enhanced by certain surgical procedures, e.g. transurethral resection of the prostate, an operative procedure commonly used in the diagnosis and management of prostatic cancer, the third biggest killer of men in the United States. Circulating tumor cells have been the subject of great controversy as they are considered to be the connecting link between the primary tumor and the hematogenously disseminated metastatic growths. Isolation and identification of tumor cells which get released into the vascular channels is somewhat complicated. We report our experience with a technique for isolating and identifying prostatic tumor cells in the circulation and briefly discuss the role of transurethral resection of the prostate in the management of prostatic cancer.

PD65-09 DOES 4K AND/OR MICHIGAN PROSTATE SCORE CHANGE CANCER DETECTION RATES IN MULTI-PARAMETRIC MRI DISCOVERED PIRADS 3 OR LOWER LESIONS?

INTRODUCTION AND OBJECTIVES: Multi-parametric magnetic resonance imaging (mp-MRI) based prostate imaging reporting and data system (PIRADS) is limited in confidently and robustly distinguishing clinically significant and insignificant prostate cancer (PCa). Radiomic features employ image processing methods to characterize specific patterns in images and have been shown to better characterize PCa than mp-MRI signal intensities alone. For example, gradient features quantify the appearance of edges, Haralick features distinguish homogenous low intensity (PCa) from normal regions and Gabor features quantify appearance of PCa at multiple orientations and scales. In this study, we aim to identify which of the mp-MRI derived radiomic features can distinguish high and low risk PCa as defined by the D’Amico criteria. METHODS: A retrospective cohort of 452 PCa patients who underwent a 3 Tesla mp-MRI scan was considered for this study. A subset of 72 patients comprising 153 lesions was chosen chronologically based on PIRADS to obtain a statistically balanced cohort. D’Amico criteria were available for 83 lesions and was used to categorize into low (N1⁄4 26), intermediate (N 1⁄4 43) and high (N 1⁄4 14) risk groups. A balanced dataset of N 1⁄4 28 lesions with 14 lesions from each of high and low risk categories was finally assembled for radiomic feature analysis. RESULTS: A set of 101 radiomic features were extracted on a voxel-wise basis within the lesion region of interest (ROI) from each of T2w and ADC MRI sequences. First order statistics (mean, variance, skewness and kurtosis) were computed within each ROI to obtain 808 features per ROI. Of these, 44 features showed statistically significant differences between high and low risk lesions. Specifically, variance and skewness of T2w gradient and Gabor features, skewness and kurtosis of ADC Haralick and Laws features showed p<0.05 using Wilcoxon Rank-Sum test (representative results are shown in Figure). A random forests classifier trained using these radiomic features within a 3-fold cross validation framework resulted in an AUC of 0.96. CONCLUSIONS: Radiomic features derived from mp-MRI distinguish high and low risk prostate cancer lesions as defined by D’Amico criteria. An independent validation of these features is required on a separate test set.