Damien Bolton

Sensitivity, Specificity, and Predictors of Positive 68Ga–Prostate-specific Membrane Antigen Positron Emission Tomography in Advanced Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT Positron emission tomography (PET) of 68Ga-labelled prostate-specific membrane antigen (68Ga-PSMA) is an emerging imaging modality introduced to assess the burden of prostate cancer, typically in biochemically recurrent or advanced disease. 68Ga-PSMA PET provides the ability to selectively identify and localize metastatic prostate cancer cells and subsequently change patient management. Owing to its limited history, robust sensitivity and specificity data are not available for 68Ga-PSMA PET-positive scans. OBJECTIVE A systematic review and meta-analysis of reported predictors of positive 68Ga-PSMA PET and corresponding sensitivity and specificity profiles. EVIDENCE ACQUISITION We performed critical reviews of MEDLINE, EMBASE, ScienceDirect, Cochrane Library, and Web of Science databases in April 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Quality was assessed using the Quality Assessment if Diagnostic Accuracy Studies-2 tool. Meta-analysis and meta-regression of proportions were performed using a random-effects model with pre-PET prostate-specific antigen (PSA) levels as the dependent variable. Summary sensitivity and specificity values were obtained by fitting bivariate hierarchical regression models. EVIDENCE SYNTHESIS Sixteen articles involving 1309 patients were analysed. The overall percentage of positive 68Ga-PSMA PET among patients was 40% (95% confidence interval [CI] 19-64%) for primary staging and 76% (95% CI 66-85%) for biochemical recurrence (BCR). Positive 68Ga-PSMA PET scans for BCR patients increased with pre-PET PSA. For the PSA categories 0-0.2, 0.2-1, 1-2, and >2 ng/ml, 42%, 58%, 76%, and 95% scans, respectively, were positive. Shorter PSA doubling time increased 68Ga-PSMA PET positivity. On per-patient analysis, the summary sensitivity and specificity were both 86%. On per-lesion analysis, the summary sensitivity and specificity were 80% and 97%, respectively. CONCLUSIONS In the setting of BCR prostate cancer, pre-PET PSA predicts the risk of positive 68Ga-PSMA PET. Pooled data indicate favourable sensitivity and specificity profiles compared to choline-based PET imaging techniques. PATIENT SUMMARY Positron emission tomography using 68Ga-labelled prostate-specific membrane antigen is an emerging radiological technique developed to improve the characterisation of metastatic prostate cancer. We summarised the data available to date and found that this new test provides excellent rates of detection of cancer spread in late-stage prostate cancer.

CLINICAL ROLE OF F-18 FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY FOR DETECTION AND MANAGEMENT OF RENAL CELL CARCINOMA

PURPOSE We evaluate the accuracy of F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) for staging and management of renal cell carcinoma. MATERIALS AND METHODS FDG-PET was performed in 25 patients with known or suspected primary renal tumors and/or metastatic disease and compared with conventional imaging techniques, including computerized tomography (CT). Histopathological confirmation was obtained in 18 patients and confirmation of the disease was by followup in the remainder. The impact of FDG-PET on disease management was also assessed. RESULTS Of the 17 patients with known or suspected primary tumors FDG-PET was true positive in 15, true negative in 1 and false-negative in 1. Comparative CT was true positive in 16 patients and false-positive in 1. The accuracy of FDG-PET and CT was similar (94%). All patients would have undergone radical nephrectomy after conventional imaging findings but FDG-PET results altered treatment decisions for 6 (35%), of whom 3 underwent partial nephrectomy and 3 avoided surgery due to confirmation of benign pathology or detection of unsuspected metastatic disease. Of the 8 cases referred for evaluation of local recurrence and/or metastatic disease FDG-PET changed treatment decisions in 4 (50%), with disease up staged in 3 and recurrence excluded in 1. Compared with CT, FDG-PET was able to detect local recurrence and distant metastases more accurately and differentiated recurrence from radiation necrosis. CONCLUSIONS FDG-PET accurately detected local disease spread and metastatic disease in patients with renal cell carcinoma and altered treatment in 40%. FDG-PET may have a role in the diagnostic evaluation of patients with renal cell carcinoma preoperatively and staging of metastatic disease.

Increase in visceral and subcutaneous abdominal fat in men with prostate cancer treated with androgen deprivation therapy.

Objective  Androgen deprivation therapy (ADT) for prostate cancer is associated with increases in fat mass and risk of type 2 diabetes; however, the relationship between sex steroid deficiency and abdominal fat distribution remains controversial.

Assessing regional hypoxia in human renal tumours using 18F-fluoromisonidazole positron emission tomography

To assess renal tumours for hypoxic regions using 18F‐fluoromisonidazole (18F‐FMISO) positron emission tomography (PET), a recognized noninvasive method for detecting hypoxia in tumours, as renal cell carcinoma (RCC) can be potentially cured with nephrectomy but recurrence develops in most patients, who then respond poorly to treatments such as chemotherapy, and hypoxia is known to confer resistance to radiotherapy and chemotherapy in many solid tumours.

Multidetector computed tomography vs magnetic resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: a study and review.

To compare the findings of multidetector computed tomography (CT) with surgical pathology and magnetic resonance imaging (MRI), to determine the accuracy of delineating the superior extent of inferior vena cava (IVC) thrombotic involvement in renal cell cancer (RCC).

Prostatic Urethral Lift: Two-year Results After Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

OBJECTIVE To evaluate the effectiveness of the prostatic urethral lift in relieving lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. METHODS A total of 64 men, aged≥55 years, with moderate to severe symptomatic benign prostatic hyperplasia were treated and followed up at 6 Australian institutions. The treatment consisted of transurethral delivery of small implants to secure the prostatic lobes in an open condition, thereby reducing obstruction of the urethral lumen. The effectiveness, including International Prostate Symptom Score, quality of life, benign prostatic hyperplasia Impact Index, and peak urethral flow rate were assessed at 2 weeks and 3, 6, 12, and 24 months. The effect of this treatment on erectile and ejaculatory function was assessed using the Sexual Health Inventory for Men and Male Sexual Health Questionnaire for Ejaculatory Dysfunction. RESULTS The prostatic urethral lift improved LUTS symptoms rapidly and durably. The International Prostate Symptom Score was reduced 42% at 2 weeks, 49% at 6 months, and 42% at 2 years in evaluable patients. The peak flow rate improved by ≥30% (2.4 mL/s) at all intervals compared with baseline. No compromise in sexual function was observed after this treatment. CONCLUSION The present study demonstrated that LUTS and flow improvements without compromising sexual function. Although this was an early study with a small cohort, this therapy shows promise as a new option for patients with LUTS.

Fine‐needle aspiration cytology predicts inguinal lymph node metastasis without antibiotic pretreatment in penile carcinoma

To evaluate the accuracy of fine‐needle aspiration (FNA) cytology of palpable inguinal lymphadenopathy before definitive management of the primary tumour, in predicting inguinal lymph node (LN) metastasis in men with primary squamous cell carcinoma (SCC) of the penis.

Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011

Objective: To describe patterns of care for men diagnosed with prostate cancer in Victoria, Australia, between 2008 and 2011.

The CROES Percutaneous Nephrolithotomy Global Study: The Influence of Body Mass Index on Outcome

PURPOSE In addition to more commonly forming stones, obese patients present a number of challenges when undergoing percutaneous nephrolithotomy. We evaluated percutaneous nephrolithotomy outcomes in 3,709 patients stratified by body mass index. MATERIALS AND METHODS A prospective database administered by CROES (Clinical Research Office of the Endourological Society) captured data on 5,803 patients treated with percutaneous nephrolithotomy between November 2007 and December 2009. Patients with known solitary kidney, previous percutaneous nephrolithotomy and congenital abnormalities were excluded from analysis. For statistical analysis patients were categorized as normal weight--body mass index 18.5 to 25 kg/m(2), overweight--25 to 30, obese--30 to 40 and super obese--greater than 40. RESULTS During the study period 5,803 patients underwent percutaneous nephrolithotomy, of whom 3,709 met the inclusion criteria. As expected, obesity was associated with significantly higher rates of comorbid conditions and anticoagulant use (p < 0.001). Operative time was significantly longer in obese patients and use of a balloon device for tract dilation was more common (each p < 0.001). The stone-free rate decreased with obesity (p = 0.009), corresponding to a significantly higher re-treatment rate in this group (p < 0.001). No difference was seen in length of stay or the transfusion rate. No significant difference was seen in the overall complication rate among the 4 groups (p = 0.707). CONCLUSIONS Percutaneous nephrolithotomy may be done safely in obese patients, although with a longer operative time, an inferior stone-free rate and a higher re-intervention rate.

Preservation of Sexual Function with the Prostatic Urethral Lift: A Novel Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

INTRODUCTION We investigated the prostatic urethral lift, a novel, minimally invasive treatment for symptomatic lower urinary tract complaints presumed to be from benign prostatic hyperplasia (BPH), which aims to mechanically open the prostatic urethra without ablation or resection. We hypothesized that this novel approach would not degrade erectile or ejaculatory function. AIMS We sought to determine the effect of the prostatic urethral lift procedure on erectile and ejaculatory function. METHODS The procedure was performed on 64 men in Australia with an average age of 66.9 years and an average duration of lower urinary tract symptom (LUTS) of 4.7 years. Primary inclusion criteria included International Prostate Symptom Score (IPSS) > 13, Qmax of 5-12 mL/second, and prostate specific antigen (PSA) < 10 ng/mL. Baseline IPSS was 22.9 ± 5.4 (N = 64). There were no inclusion criteria for sexual function. Baseline Sexual Health Inventory for Men (SHIM) was 11.7 ± 8.6 (N = 58); baseline Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EjD) function score was 9.0 ± 3.7 (N = 46); and lack of sexual activity or unwillingness to answer sexual function questionnaires accounted for the reduced sample size in the sexual function instruments. Implants were placed to separate encroaching lateral prostatic lobes. MAIN OUTCOME MEASURES Patients were evaluated at 6 weeks and 3, 6, and 12 months postprocedure via the SHIM and MSHQ-EjD instruments. RESULTS There was no evidence of degradation in sexual function after treatment for LUTS with the prostatic urethral lift procedure. Erectile function, as measured by SHIM, was slightly increased at all time points as compared with baseline. No patient reported retrograde ejaculation at any follow-up visit. CONCLUSIONS We demonstrated significant improvement in LUTS with no evidence of degradation in erectile or ejaculatory function after treatment with the prostatic urethral lift procedure. This procedure warrants further study as a new option for patients underserved by current treatments for LUTS/BPH.