Efrat Tsivian

Navigating MRI-TRUS fusion biopsy: optimizing the process and avoiding technical pitfalls

ABSTRACT Multi-parametric MRI (mpMRI) is widely used in the detection and characterization of clinically- significant prostate cancer. MRI-TRUS (trans-rectal ultrasound) fusion biopsy is an in-office procedure that promises to empower urologists to successfully target these MRI-visible lesions for histological confirmation. We describe the moving parts in the process and discuss methods to optimize biopsy outcomes. mpMRI is highly technical and reader-dependent. The acquisition of US images to generate a valid 3D US model and subsequent registration and fusion requires the urologist to attain equilibrium of probe position and pressure to achieve maximum registration accuracy. Environmental, medical and engineering measures can be undertaken to improve targeting accuracy. The art and skill of ‘hitting’ a visual target involves real-time recognition and adjustment for potential errors/ mis-registration in the fusion guide. A multi-disciplinary team effort is critical to improve all steps of the procedure.

The Contemporary Role of Multiparametric Magnetic Resonance Imaging in Active Surveillance for Prostate Cancer

Purpose of ReviewGrowing research supports the use of multiparametric magnetic resonance imaging (mpMRI) for the evaluation of localized prostate cancer (PCa). We highlight contemporary evidence supporting its use in active surveillance (AS).Recent FindingsThe emerging approach to localized PCa favors risk-adapted screening, image-guided biopsies, and selective therapeutic interventions. mpMRI is increasingly critical to achieve each of these aims. Early evidence suggests a value of mpMRI before initial biopsy to guide fusion targeting and to rule out non-organ confined disease as well as in the initiation and serial monitoring of men on AS. There remain concerns regarding understaging cancer with mpMRI and the standardization of expertise beyond the most experienced centers.SummarympMRI is emerging as a critical decision point for staging localized PCa and guiding AS strategies. While there is increasing enthusiasm, the optimal clinical scenario and sequencing remains to be defined.

Validation of the 2015 prostate cancer grade groups for predicting long-term oncologic outcomes in a shared equal-access health system

A 5‐tier prognostic grade group (GG) system was enacted to simplify the risk stratification of patients with prostate cancer in which Gleason scores of ≤6, 3 + 4, 4 + 3, 8, and 9 or 10 are considered GG 1 through 5, respectively. The authors investigated the utility of biopsy GG for predicting long‐term oncologic outcomes after radical prostatectomy in an equal‐access health system.

Body mass index and the clinicopathological characteristics of clinically localized renal masses—An international retrospective review

OBJECTIVES To investigate the potential association between body mass index (BMI) and clinicopathological features of clinically localized renal masses. MATERIALS AND METHODS An international, multi-institutional retrospective review of patients who underwent surgery for clinically localized renal masses between 2000 and 2010 was undertaken after an institutional review board approval. Patients were divided into 4 absolute BMI groups based on the entire cohort׳s percentiles and 4 relative BMI groups based on their respective population (American or Italian). Renal mass pathological diagnosis, renal cell carcinoma (RCC) subtype, Fuhrman grade (low and high), and clinical stage were compared among groups using Fisher׳s exact test, Kruskal-Wallis test, and the Cochran-Armitage trend test. A multivariate logistic analysis was performed to evaluate independent association between tumor and patient characteristics with tumor pathology (Fuhrman grade). RESULTS A total of 1,748 patients having a median BMI of 28 (interquartile range 25-32) were evaluated. Benign masses and RCC cases had similar proportion across BMI groups (P = 0.4). The most common RCC subtype was clear cell followed by papillary carcinoma, chromophobe, and other subtypes. Their distribution was comparable across BMI groups (P = 0.7). Similarly, clinical stage distribution was comparable with the overall cohort. The distribution of Fuhrman grade in RCC, however, demonstrated an increased proportions of low grade with increasing BMI (P<0.05). This trend was maintained in subgroups according to gender, stage and age (P<0.05 in all subgroup analysis). In a multivariable model that included potential confounders (i.e., age, sex, and tumor size) higher BMI groups had lower odds of presenting a high Fuhrman grade. CONCLUSION In this study, higher BMI was associated with lower grade of RCC in clinically localized renal masses. This may, in part, explain better survival rates in patients with higher BMI and may correlate with a possible link between adipose tissue and RCC biology.

Assessing clinically significant prostate cancer: Diagnostic properties of multiparametric magnetic resonance imaging compared to three‐dimensional transperineal template mapping histopathology

To evaluate the diagnostic properties of multiparametric magnetic resonance imaging in the detection, localization and characterization of prostate cancer using three‐dimensional transperineal template mapping biopsy histopathology as the comparator.

New advances in focal therapy for early stage prostate cancer

ABSTRACT Introduction: Prostate focal therapy offers men the opportunity to achieve oncological control while preserving sexual and urinary function. The prerequisites for successful focal therapy are to accurately identify, localize and completely ablate the clinically significant cancer(s) within the prostate. We aim to evaluate the evidence for current and upcoming technologies that could shape the future of prostate cancer focal therapy in the next five years. Areas covered: Current literature on advances in patient selection using imaging, biopsy and biomarkers, ablation techniques and adjuvant treatments for focal therapy are summarized. A literature search of major databases was performed using the search terms ‘focal therapy’, ‘focal ablation’, ‘partial ablation’, ‘targeted ablation’, ‘image guided therapy’ and ‘prostate cancer’. Expert commentary: Advanced radiological tools such as multiparametric magnetic resonance imaging (mpMRI), multiparametric ultrasound (mpUS), prostate-specific-membrane-antigen positron emission tomography (PSMA-PET) represent a revolution in the ability to understand cancer function and biology. Advances in ablative technologies now provide a menu of modalities that can be rationalized based on lesion location, size and perhaps in the near future, pre-determined resistance to therapy. However, these need to be carefully studied to establish their safety and efficacy parameters. Adjuvant strategies to enhance focal ablation are under development.

Effect of blood transfusions on oncological outcomes of surgically treated localized renal cell carcinoma

OBJECTIVE To assess the associations between perioperative allogeneic blood transfusions (ABTs) and recurrence, overall and renal cell carcinoma (RCC)-specific survival in patients undergoing surgical treatment for clinically localized disease. MATERIALS AND METHODS We performed a retrospective review of 1,056 consecutive patients undergoing surgical treatment (radical or partial nephrectomy) for clinically localized RCC between 2000 to 2010. Demographic (age, race, and sex) clinical (preoperative hemoglobin and hematocrit, type of surgery [partial or radical nephrectomy]), and pathological (T and N stages, RCC histotype, grade) data were compared between patients receiving perioperative (intraoperative or postoperative) blood transfusions and those who are not. Distant and local recurrence-free survival, overall survival, RCC-specific survival were recorded and Kaplan-Meier survival curves as well as multivariable proportional regression models adjusted for clinical and pathological characteristics were produced. RESULTS On multivariable analyses adjusted for clinical and pathological characteristics, the receipt of ABTs was associated with lower recurrence-free (HR = 1.86, P = 0.002), overall (HR = 1.83, P = 0.016), and RCC-specific survival (HR = 2.12, P = 0.031). The negative effect of ABTs was apparent for distant (HR = 2.24, P<0.001) but not local recurrences (HR = 0.78, P = 0.643). Limitations include retrospective nature and lack of uniform criteria for blood transfusion during the study period. CONCLUSIONS In this study, perioperative ABTs were independently associated with worse oncological outcomes in patients with clinically localized RCC. Receipt of ABT was associated with roughly a 2-fold increase in the hazard of metastatic progression, all-cause and RCC-specific mortality. Further research is needed on the mechanisms of transfusion-induced immunomodulation, alternative transfusion protocols and methods for autologous blood transfusion and recovery.

MP18-16 PROPENSITY SCORE MATCHED COMPARISON OF PARTIAL TO WHOLE GLAND CRYOTHERAPY FOR INTERMEDIATE-RISK PROSTATE CANCER: AN ANALYSIS OF THE COLD REGISTRY DATA

Introduction: Patients with intermediate-risk prostate cancer constitute a unique group of patients in whom cure may be both necessary and possible. While there has been increasing interest in partial gland therapies to reduce the morbidity of treatment, randomized comparisons to whole gland therapies have been lacking. We aim to compare the oncological and functional outcomes of partial versus whole gland cryotherapy for intermediate-risk prostate cancer.

Primary care perspective and implementation of a multidisciplinary, institutional prostate cancer screening algorithm embedded in the electronic health record

PURPOSE In response to controversy regarding prostate cancer (CaP) screening recommendations, a consolidated Duke Cancer Institute (DCI) multidisciplinary algorithm for CaP screening was developed and implemented. We conducted an online survey within the year following its implementation to assess primary care provider (PCP) attitudes and adoption as well as to evaluate how this program affects screening rates. METHODS A web-based 18-item survey was programmed and was electronically mailed to practicing PCPs at clinics affiliated with the Duke Primary Care system. The survey assessed provider practices and attitudes regarding CaP screening, factors that influenced their general screening recommendations and the confidence related to communicating with patients about screening. The rate of PSA screening before and after implementation of the algorithm was reported across age and race categories. RESULTS In sum, 94 of 106 respondents (88.6%) reported discussing the benefits and harms of screening and let their patients decide (52.8%) or recommended for (31.1%) or against (4.7%) screening. Three-fourths of respondents followed a specific panel recommendation such as the United States Preventative Services Task Force (USPSTF) (48.1%), DCI (20%), or the American Urological Association (AUA) (7.4%) guidelines. After integrating this algorithm into the electronic health record, the rate of prostate screening increased between 11% and 20.4% and 15.6% and 16.4% among different age and race categories, respectively. Overall, 79.2% of PCPs felt very confident regarding their ability to communicate the topic of CaP screening with patients. CONCLUSION The DCI multidisciplinary CaP screening algorithm was well adopted among PCPs shortly after its implementation. The rate of screening increased among all age and race categories thereafter. The majority of PCPs involved in this survey felt confident regarding their CaP screening knowledge and most discuss this topic with patients in a shared decision-making model.

Predictors of Rectourethral Fistula Formation After Primary Whole-Gland Cryoablation for Prostate Cancer: Results from the Cryo On-Line Database Registry

PURPOSE To define the incidence and risk factors associated with rectourethral fistula (RUF) formation following primary whole-gland cryosurgery using a multicenter centralized registry. PATIENTS AND METHODS The Cryo On-Line Data (COLD) registry was queried for men undergoing primary whole-gland cryotherapy between 1990 and 2014 who developed a RUF. Patient factors and disease parameters were correlated with RUF using chi-square and the t-test. Variables with p < 0.25 were entered into a binary logistic regression with stepwise backward elimination to determine the factors associated with RUF formation. RESULTS A total of 4102 men underwent primary whole-gland cryotherapy in the COLD registry at the time of analysis. Postoperative RUF was documented in 50 out of 4102 cases (1.2%). Patients with RUF had similar demographic data, prostate volume, preoperative prostate-specific antigen level, and clinical stage in comparison to those without fistula. On both univariate and multivariate analyses, postoperative urinary retention (odds ratio [OR]: 6.30; confidence interval [95% CI] 3.43-11.58, p < 0.001), preoperative Gleason score of ≥7 (OR: 1.92; 95% CI 1.08-3.43, p = 0.027), and preoperative incontinence (OR: 2.95; 95% CI 1.12-7.76, p = 0.028) were the most significant risk factors associated with RUF formation. CONCLUSION Primary whole-gland cryotherapy for prostate cancer is associated with a historically low rate (1.2%) of postoperative RUF formation. The rate decreased further to 0.55% over the last several years, suggesting better patient selection and technical improvement. Postoperative urinary retention, Gleason score ≥7, and preoperative urinary incontinence were the key demographic, clinical, and pathologic features associated with RUF formation in this study.