Giorgio Brembilla

Preoperative multiparametric MRI of the prostate for the prediction of lymph node metastases in prostate cancer patients treated with extended pelvic lymph node dissection

AbstractObjectivesTo assess the role of preoperative multiparametric MRI (mpMRI) of the prostate in the prediction of nodal metastases in patients treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND).MethodsWe retrospectively analyzed 101 patients who underwent both preoperative mpMRI of the prostate and RP with ePLND at our institution. For each patient, complete preoperative clinical data and tumour characteristics at mpMRI were recorded. Final histopathologic stage was considered the standard of reference. Univariate and multivariate logistic regression analyses were performed.ResultsNodal metastases were found in 23/101 (22.8%) patients. At univariate analyses, all clinical and radiological parameters were significantly associated to nodal invasion (all p<0.03); tumour volume at MRI (mrV), tumour ADC and tumour T-stage at MRI (mrT) were the most accurate predictors (AUC = 0.93, 0.86 and 0.84, respectively). A multivariate model including PSA levels, primary Gleason grade, mrT and mrV showed high predictive accuracy (AUC = 0.956). Observed prevalence of nodal metastases was very low among tumours with mrT2 stage and mrV<1cc (1.8%).ConclusionPreoperative mpMRI of the prostate can predict nodal metastases in prostate cancer patients, potentially allowing a better selection of candidates to ePLND.Key points• Multiparametric-MRI of the prostate can predict nodal metastases in prostate cancer • Tumour volume and stage at MRI are the most accurate predictors • Prevalence of nodal metastases is low for T2-stage and <1cc tumours • Preoperative mpMRI may allow a better selection of candidates to lymphadenectomy

Embolization of superior rectal arteries for transfusion dependent haemorrhoidal bleeding in severely cardiopathic patients: a new field of application of the “emborrhoid” technique

Hemorrhoids are one of the most common anorectal diseases, with a prevalence of 4–86% [1]. One of the main symptoms is recurrent painless anorectal bleeding during defecation, which, if overlooked, can cause anemia. Embolization of the superior rectal arteries (“emborrhoid technique”) with coils was recently proposed by Vidal et al. [2] as a less invasive alternative to well-known conventional surgical treatments for hemorrhoids causing significant complication. This technique has been shown to be effective, safe, and well tolerated in patients with hemorrhoidal bleeding unsuitable or unwilling to undergo surgical treatment [3]. Anticoagulant and antiplatelet therapy is crucial in many patients with chronic heart disease to avoid lifethreatening thrombotic complications after cardiac surgery, coronary artery stenting, or left ventricular assist devices (LVAD) implantation, in patients experiencing heart failure. Treatment of severe hemorrhoidal bleeding in this group of “high-risk” surgical patients may be challenging, and they may benefit from non-surgical dearterialization. Technique Two patients, with severe heart disease and bleeding hemorrhoids causing severe anemia requiring blood transfusion, were both treated with the “emborrhoid technique”. Written informed consent was obtained from both patients. The first patient was a 71-year-old man with acute coronary syndrome, previously treated with multiple stent implantation and dual antiplatelet therapy (acetylsalicylic acid and clopidogrel), admitted to the intensive care department for anorectal bleeding and anemia (hemoglobin level 9 g/dL) despite iron supplementation and blood transfusions. A conventional hemorrhoidectomy was not recommended due to the high bleeding risk and the high risk of stopping antiplatelet therapy. The second patient was a 70-year-old man with severe dilated cardiomyopathy and with a heart mate II® (Thoratec Corp, Pleasanton, CA, USA) LVAD implant, as a bridge to heart transplantation; the patient was on long term warfarin therapy with international normal ratio (INR) of 2.5, also admitted to the intensive care department. He suffered severe hemorrhoidal bleeding requiring daily blood transfusions and was also admitted to the intensive care department. Both patients were treated with coil embolization of the terminal branches of the superior rectal arteries. After trans-femoral placement of a 4-F introducer and subsequent catheterization of the inferior mesenteric artery with a 4-F Simmons catheter (Cordis/Johnson and Johnson, Warren, NJ, USA), a preliminary diagnostic angiography was performed to visualize the superior rectal arteries and to identify the possible sources of bleeding (Fig. 1). The terminal branches of both superior rectal arteries were easily catheterized with a coaxial microcatheter (Renegade high flow, Boston Scientific, Marlborough, MA, USA) and then embolized (Fig. 2) using 0.025′′, 3-mm-diameter, 3-cmlong pushable coils (Cook, Bloomington, IN, USA). The post embolization angiogram showed the lack of opacification of the terminal branches of the superior rectal arteries and cessation of bleeding (Fig. 3). At the end of the procedure, prolonged manual compression (30–45 min) was performed after the removal of the femoral introducer. The * P. De Nardi denardi.paola@hsr.it

MP03-05 NOT ALL MPMRI TARGETED BIOPSIES ARE EQUAL: THE IMPACT OF THE TYPE OF APPROACH AND OPERATOR EXPERTISE ON THE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER

METHODS: A review was performed of a prospectively maintained database of patients undergoing mpMRI followed by fusion biopsy (Fbx) and systematic biopsy (Sbx) from 2007 to 2016. The patients were stratified based on the timing of first biopsy in 3 groups. Cohort 1 included patients biopsied between 7/2007 to 12/ 2010, accounting for learning curve at our institution. Cohort 2 included patients biopsied from 1/2011 up to the debut of UroNav (Invivo) platform in 5/2013. Cohort 3 included patients biopsied after 5/ 2013. Clinically significant (CS) disease was defined as Gleason 7 (3+4) or higher. Cancer detection rates (CDR) between Sbx and Fbx during different time periods were compared using McNemar test. Age and PSA standardized CDRs were calculated for comparison between 3 cohorts. RESULTS: 1528 patients were included in the study with 219, 549 and 761 patients included in 3 respective cohorts. Mean age, PSA and race distribution were similar across 3 cohorts. In cohort 1 there was no significant difference between CDR of CS disease by Fbx (24.7%) vs Sbx (21.5%), p1⁄40.377. Fbx was significantly better than Sbx in detection of CS disease in cohort 2 and cohort 3 (31.5% vs 25.3%, p1⁄40.001; 36.5% vs 30.2%, p<0.001, respectively). There was significant decline in the detection of low risk disease by Fbx when compared to Sbx in the same period (cohort 2: 14.2% vs 20.9%, p<0.001; cohort 3: 12.5% vs 19.5%, p<0.001). Age and PSA standardized CDR of CS cancer by Fbx increased significantly between each successive cohort (cohort 1 and 2: 5.2%, 95% CI [2.1-8.5]), 2 and 3 (5.2%, 95% CI [1.88.6]). While CS CDR in patients with a prior negative biopsy was not significantly different between Fbx and Sbx in cohort 1, it was significantly different in cohorts 2 and 3 (p1⁄40.388, p>0.001, p1⁄40.036, respectively). CONCLUSIONS: Our results show that after an early learning period using Fbx, CS prostate cancer was detected at significantly higher rates with Fbx than with Sbx, and low risk disease was detected at lower rates. Advances in software allowed for even greater detection of CS disease in the last cohort. This study shows that accuracy of Fbx is dependent on multiple factors; surgeon/radiologist experience and software improvements together produce improved accuracy.

MP77-15 INCLUSION OF MPMRI INTO THE EUROPEAN RANDOMIZED STUDY OF SCREENING FOR PROSTATE CANCER (ERSPC) RISK CALCULATOR: A NEW PROPOSAL TO IMPROVE THE ACCURACY OF PROSTATE CANCER DETECTION

INTRODUCTION AND OBJECTIVES: Chemoprevention of prostate cancer has long been an interesting topic. Data have shown that Metformin is associated with lower prostate specific antigen levels. A recent study showed that Metformin can modify gene expression in prostate cancer cells. Literature is controversial on the role of metformin in prostate cancer prevention. This study was designed to assess relationship of diabetes mellitus and metformin with prostate cancer. METHODS: A database of patients with prostate cancer was searched for patients with diabetes mellitus taking medications. Patients with diabetes mellitus prior to prostate cancer detection were detected. Data were imported into SPSS v. 21 for analysis. After primary analysis, patients taking metformin were compared to diabetic patients not taking metformin and non-diabetic patients. RESULTS: Between March 2003 and October 2016, there were 3,645 patients in the database of which 228 (6.2%) were diagnosed with diabetes mellitus prior to the time of prostate cancer detection. In diabetic group, 139 patients were using metformin products prior to surgery. There were additional 35 patients who were taking metformin for other conditions rather than diabetes mellitus. A general comparison of characteristics of diabetic and non-diabetic patients in the study is shown in table 1. Diabetic patients were more commonly black, had higher BMI, Higher D’Amico risk and higher American Society of Anesthesiologist risk classification (all p<0.05). There was no significant difference between diabetic patients taking metformin and diabetic patients on other treatment plans. Analysis of patients taking metformin with other patients (diabetic and non-diabetic) showed no significant difference in terms of prostate cancer characteristics. CONCLUSIONS: Diabetes mellitus might impact the course of prostate cancer development. The results of the study does not support the protective effect of metformin on prostate cancers in diabetic or nondiabetic.

Therapeutic EUS: Biliary drainage - The interventional radiologist's perspective

Up to 75% of patients with pancreatic cancer develop symptomatic biliary obstruction[1] and both the most recent guidelines from the European Society of Medical Oncology (ESMO)[2] and the National Comprehensive Cancer Network (NCCN) strongly recommend the endoscopic approach for the placement of a metallic biliary stent. Although biliary drainage (BD) is strongly recommended as palliation in advanced pancreatic cancer to provide relief of biliary and/or duodenal obstruction, malnutrition, and pain,[2] studies do not recommend presurgical BD.[3,4] However, based on the most recent evidence, including a randomized controlled trial, both the ESMO and NCCN guidelines suggest routine preoperative BD only in selected patients with symptomatic jaundice, cholangitis, or with an expected delay to surgery.[2,5,6]