Dmitry Volkin

Multiparametric Magnetic Resonance Imaging and Ultrasound Fusion Biopsy Detect Prostate Cancer in Patients with Prior Negative Transrectal Ultrasound Biopsies

PURPOSE Patients with negative transrectal ultrasound biopsies and a persistent clinical suspicion are at risk for occult but significant prostate cancer. The ability of multiparametric magnetic resonance imaging/ultrasound fusion biopsy to detect these occult prostate lesions may make it an effective tool in this challenging scenario. MATERIALS AND METHODS Between March 2007 and November 2011 all men underwent prostate 3 T endorectal coil magnetic resonance imaging. All concerning lesions were targeted with magnetic resonance imaging/ultrasound fusion biopsy. In addition, all patients underwent standard 12-core transrectal ultrasound biopsy. Men with 1 or more negative systematic prostate biopsies were included in our cohort. RESULTS Of the 195 men with previous negative biopsies, 73 (37%) were found to have cancer using the magnetic resonance imaging/ultrasound fusion biopsy combined with 12-core transrectal ultrasound biopsy. High grade cancer (Gleason score 8+) was discovered in 21 men (11%), all of whom had disease detected with magnetic resonance imaging/ultrasound fusion biopsy. However, standard transrectal ultrasound biopsy missed 12 of these high grade cancers (55%). Pathological upgrading occurred in 28 men (38.9%) as a result of magnetic resonance imaging/ultrasound fusion targeting vs standard transrectal ultrasound biopsy. The diagnostic yield of combined magnetic resonance imaging/ultrasound fusion platform was unrelated to the number of previous negative biopsies and persisted despite increasing the number of previous biopsy sessions. On multivariate analysis only prostate specific antigen density and magnetic resonance imaging suspicion level remained significant predictors of cancer. CONCLUSIONS Multiparametric magnetic resonance imaging with a magnetic resonance imaging/ultrasound fusion biopsy platform is a novel diagnostic tool for detecting prostate cancer and may be ideally suited for patients with negative transrectal ultrasound biopsies in the face of a persistent clinical suspicion for cancer.

Low Suspicion Lesions on Multiparametric Magnetic Resonance Imaging Predict for the Absence of High Risk Prostate Cancer

Study Type – Diagnostic (case series) Level of Evidence 4 Whats known on the subject? and What does the study add? Over‐treatment of indolent prostate cancer lesions is a problem which can result in increased human and medical costs. Lesions with a low suspician level at mpMRI of the prostate have low risk of including high risk prostate cancer.

Multiparametric magnetic resonance imaging (MRI) and subsequent MRI/ultrasonography fusion-guided biopsy increase the detection of anteriorly located prostate cancers

To describe the detection rate of anteriorly located prostate cancer (PCa) with the addition of magnetic resonance imaging (MRI)/ultrasonography (US) fusion‐guided biopsy (FGB) to the standard transrectal ultrasonography (TRUS)‐guided biopsy.

Very distal apical prostate tumours: identification on multiparametric MRI at 3 Tesla.

Study Type – Diagnosis (case series)

Partial adrenalectomy minimizes the need for long-term hormone replacement in pediatric patients with pheochromocytoma and von Hippel-Lindau syndrome.

PURPOSE Children with von Hippel-Lindau syndrome (VHL) are at an increased risk for developing bilateral pheochromocytomas. In an effort to illustrate the advantage of partial adrenalectomy (PA) over total adrenalectomy in children with VHL, we report the largest single series on PA for pediatric patients with VHL, demonstrating a balance between tumor removal and preservation of adrenocortical function. METHODS From 1994 to 2011, a prospectively maintained database was reviewed to evaluate 10 pediatric patients with hereditary pheochromocytoma for PA. Surgery was performed if there was clinical evidence of pheochromocytoma and if normal adrenocortical tissue was evident on preoperative imaging and/or intraoperative ultrasonography. Perioperative data were collected, and patients were observed for postoperative steroid use and tumor recurrence. RESULTS Ten pediatric patients with a diagnosis of VHL underwent 18 successful partial adrenalectomies (4 open, 14 laparoscopic). The median tumor size removed was 2.6 cm (range, 1.2-6.5 cm). Over a median follow-up of 7.2 years (range, 2.6-15.8 years), additional tumors in the ipsilateral adrenal gland were found in 2 patients. One patient underwent completion adrenalectomy, and 1 underwent a salvage PA with resection of the ipsilateral lesion. One patient required short-term steroid replacement therapy. At last follow-up, 7 patients had no radiographic or laboratory evidence of pheochromocytoma. CONCLUSION At our institution, PA is the preferred form of management for pheochromocytoma in the (VHL) pediatric population. This surgical approach allows for removal of tumor while preserving adrenocortical function and minimizing the adverse effects of long-term steroid replacement on puberty and quality of life.

Magnetic resonance imaging (MRI)-guided transurethral ultrasound therapy of the prostate: A preclinical study with radiological and pathological correlation using customised MRI-based moulds

To characterise the feasibility and safety of a novel transurethral ultrasound (US)‐therapy device combined with real‐time multi‐plane magnetic resonance imaging (MRI)‐based temperature monitoring and temperature feedback control, to enable spatiotemporally precise regional ablation of simulated prostate gland lesions in a preclinical canine model. To correlate ablation volumes measured with intra‐procedural cumulative thermal damage estimates, post‐procedural MRI, and histopathology.

Image guidance in the focal treatment of prostate cancer.

Purpose of review The advent of prostate-specific antigen screening has led to a seven-fold increase in the incidence of prostate cancer without a resultant decrease in mortality rate. This has led to the belief that urologists are overdetecting and overtreating clinically insignificant disease. To maintain the delicate balance between high cancer cure rate and overtreatment, which could potentially lead to unnecessary morbidities, focal therapy has emerged as the reasonable middle ground. In this article, we present the conceptual basis and the challenges of focal therapy, while emphasizing the critical role of imaging in focal treatment of prostate cancer. Recent findings Multiple phase I trials have demonstrated the feasibility, short-term efficacy, and safety of focal therapy. Fundamental to the success of these trials and the ultimate acceptance of focal therapy is the integral role of imaging in optimal patient selection. Among the different imaging modalities, only ultrasound and multiparametric MRI are intimately involved in the detection, diagnosis, staging, and treatment of prostate cancer. Each modality has its own unique advantages and shortcomings. Recent advances in enhanced ultrasound modalities, functional MRIs, and biopsy platforms have taken focal therapy one step closer to becoming the standard of care. Summary Although early results of phase I focal therapy trials are encouraging, long-term oncological outcomes remain to be elucidated. Incorporation of these technological advances into large prospective trials is needed to establish focal therapy as an important asset in the urologists armamentarium against prostate cancer.

V10-01 RECONSTRUCTION OF TWO CONCURRENT IPSILATERAL URETERAL STRICTURES WITH APPENDICEAL ONLAY AND NON-TRANSECTING URETERAL REIMPLANT

(RC) for muscle-invasive urothelial carcinoma of the bladder (UCB) failed to meet its accrual target. We sought to examine the comparative effectiveness of TMT vs. RC for muscle-invasive UCB in an observational cohort study. METHODS: Within the National Cancer Data Base (20042011), we identified 12,843 individuals who received TMT or RC for definitive treatment of cN0M0 muscle-invasive UCB. Inverse probability of treatment weighting (IPTW) adjusted Kaplan-Meier and Cox regression analyses with time-varying covariate were used to compare overall survival (OS) of patients who received TMT vs. RC. Exploratory analyses according to patient characteristics were also performed. RESULTS: Overall, 1,257 (9.8%) and 11,586 (90.2%) patients received TMT and RC, respectively. IPTW-adjusted Kaplan-Meier curves showed that median OS was similar between TMT and RC groups (39.6 [95% CI, 33.7-45.5] vs. 43.0 [95% CI, 40.9-45.1] months; P1⁄40.290; Figure 1). In IPTW-adjusted Cox regression analysis with time-varying covariate, TMT was associated with a significant adverse effect on OS after 25 months of follow-up (HR1⁄41.37;95%CI1⁄4[1.16-1.59];p<0.001). In exploratory analyses (Figure 2), there was no significant difference between TMT and RC with regard to long-term OS in individuals aged >1⁄470 (HR1⁄41.21;95% CI1⁄4[0.83-1.60];P1⁄40.225), of female gender (HR1⁄41.28;95%CI1⁄4[0.831.74];P1⁄40.170), with Charlson comorbidity index >1⁄41 (HR1⁄41.10;95% CI1⁄4[0.83-1.38];P1⁄40.439) and/or >1⁄4cT3 disease (HR1⁄41.16; 95% CI1⁄4[0.80-1.52];P1⁄40.338. CONCLUSIONS: We generally observed that TMT was associated with worse long-term OS compared to RC for muscle-invasive UCB. However, selected subgroups of patients may choose TMT over RC to avoid surgical toxicities with minimal impact on OS.

2053 MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING AND ULTRASOUND FUSION BIOPSY DETECTS PROSTATE CANCER IN PATIENTS WITH PRIOR NEGATIVE TRUS BIOPSIES

Results: One hundred ninety-five patients had previous negative biopsies. Median age was 62 years (37–80), median number of previous biopsies was 2 (1–9), and median PSA was 9.13 ng/mL (0.3– 103). Of the 195 pts, 73 (37%) were found to have cancer using both modalities at our institution. MRI/US fusion biopsy detected cancer in 59 pts (81%). High grade cancer (Gleason 8 and above) was found in 21 of the 195 pts (11%). All 21 patients (100%) were detected on MRI/US fusion biopsy while TRUS biopsy missed 12 of these high grade cancers (55%).