Michael Kongnyuy

Magnetic Resonance Imaging-Transrectal Ultrasound Guided Fusion Biopsy to Detect Progression in Patients with Existing Lesions on Active Surveillance for Low and Intermediate Risk Prostate Cancer

Purpose: Active surveillance is an established option for men with low risk prostate cancer. Multiparametric magnetic resonance imaging with magnetic resonance imaging‐transrectal ultrasound fusion guided biopsy may better identify patients for active surveillance compared to systematic 12‐core biopsy due to improved risk stratification. To our knowledge the performance of multiparametric magnetic resonance imaging in following men on active surveillance with visible lesions is unknown. We evaluated multiparametric magnetic resonance imaging and magnetic resonance imaging‐transrectal ultrasound fusion guided biopsy to monitor men on active surveillance. Materials and Methods: This retrospective review included men from 2007 to 2015 with prostate cancer on active surveillance in whom magnetic resonance imaging visible lesions were monitored by multiparametric magnetic resonance imaging and fusion guided biopsy. Progression was defined by ISUP (International Society of Urological Pathology) grade group 1 to 2 and ISUP grade group 2 to 3. Significance was considered at p ≤0.05. Results: A total of 166 patients on active surveillance with 2 or more fusion guided biopsies were included in analysis. Mean followup was 25.5 months. Of the patients 29.5% had pathological progression. Targeted biopsy alone identified 44.9% of patients who progressed compared to 30.6% identified by systematic 12‐core biopsy alone (p = 0.03). Fusion guided biopsy detected 26% more cases of pathological progression on surveillance biopsy compared to systematic 12‐core biopsy. Progression on multiparametric magnetic resonance imaging was the sole predictor of pathological progression at surveillance biopsy (p = 0.013). Multiparametric magnetic resonance imaging progression in the entire cohort had 81% negative predictive value, 35% positive predictive value, 77.6% sensitivity and 40.5% specificity in detecting pathological progression. Conclusions: Multiparametric magnetic resonance imaging progression predicts the risk of pathological progression. Patients with stable multiparametric magnetic resonance imaging findings have a low rate of progression. Incorporating fusion guided biopsy in active surveillance nearly doubled our detection of pathological progression compared to systematic 12‐core biopsy.

Bilateral Ureteral-Iliac Artery Fistula in a Patient with Chronic Indwelling Ureteral Stents: A Case Report and Review

Ureteral-arterial fistula (UAF) is an exceedingly rare but life-threatening condition warranting emergent intervention. Prompt recognition and management of UAF in suspect patients presenting with gross hematuria are required for a successful outcome. We report a rare subset of UAF involving the bilateral common iliac arteries. The patient underwent successful endovascular stent-grafting to correct the arterial defect and delayed open repair of the ureteral strictures. Timely management has benefited from the collaboration of the involved medical teams, which included emergency medicine, urology, and interventional radiology.

Effects of Focal Versus Total Cryotherapy and Minimum Tumor Temperature on Patient-Reported Quality of Life as Compared to Active Surveillance in Prostate Cancer Patients

OBJECTIVE To investigate the effects of focal (hemiablation) or total cryotherapy and minimum tumor temperature on patient-reported quality of life (QoL) in patients with prostate cancer. METHODS An Institutional Review Board-approved database was reviewed for patients who underwent cryotherapy or active surveillance (AS). QoL questionnaire responses were collected and scores were analyzed for differences between focal and total cryotherapy and between very cold (<-76°C) and moderate-cold (≥-76°C) minimum tumor temperatures. RESULTS A total of 197 patients responded to a total of 547 questionnaires. Focal and total cryotherapy patients had initially lower sexual function scores relative to AS (year 1 mean difference focal: -31.7, P <.001; total: -48.1, P <.001). Focal cryotherapy was associated with a more rapid improvement in sexual function. Both focal and total cryotherapy sexual function scores were not statistically significantly different from the AS cohort by postprocedural year 4. Very cold and moderate-cold temperatures led to initially lower sexual function scores relative to AS (year 1 very cold: -38.1, P <.001; moderate-cold: -30.7, P <.001). Moderate-cold temperature scores improved more rapidly than those of very cold temperature. Neither very cold nor moderate-cold temperatures had a statistically significant difference in sexual function scores relative to AS by postprocedural year 4. Urinary function and bowel habits were not significantly different between focal and total cryotherapy and between very cold and moderate-cold temperature groups. CONCLUSION Focal cryotherapy and moderate-cold (≥-76°C) temperature were associated with favorable sexual function relative to total cryotherapy and very cold temperature, respectively. No significant differences in urinary function or bowel habits were observed between groups.

A Rare Case of the Simultaneous, Multifocal, Metastatic Renal Cell Carcinoma to the Ipsilateral Left Testes, Bladder, and Stomach.

We describe the rare case of a 68-year-old gentleman with the history of a hand-assisted laparoscopic left radical nephrectomy for a T2bN0M1 clear cell renal cell carcinoma (RCC). Seven years after surgery and with clean surveillance imaging for metastasis/recurrence the patient presented with three separate tumors suspicious for malignancy. A bladder lesion was found during workup for hematuria, a stomach lesion during diagnostic endoscopy, and a testicular lesion during self-exam. He underwent transurethral resection of bladder tumor, left inguinal orchiectomy, and upper endoscopic ensnarement. All specimens surprisingly showed RCC by histology and immunostaining. These three sites are rare for RCC metastasis and simultaneous presentation is even rarer, further emphasizing the importance of continuous and careful follow-up in this patient population, despite what could appear as complete remission.

Patient-reported quality of life progression in men with prostate cancer following primary cryotherapy, cyberknife, or active holistic surveillance

BackgroundTechnological advancements have led to the success of minimally invasive treatment modalities for prostate cancer such as CyberKnife and Cryotherapy. Here, we investigate patient-reported urinary function, bowel habits, and sexual function in patients following CyberKnife (CK) or Cryotherapy treatment, and compare them with active holistic surveillance (AHS) patients.MethodsAn IRB-approved institutional database was retrospectively reviewed for patients who underwent CK, Cryotherapy, or AHS. Quality of life (QoL) survey responses were collected every three months and the mean function scores were analyzed in yearly intervals over the 4 years post-treatment.Results279 patients (767 survey sets) were included in the study. There was no difference among groups in urinary function scores. The CyberKnife group had significantly lower bowel habit scores in the early years following treatment (year 2 mean difference: −5.4, P < 0.01) but returned to AHS level scores by year 4. Cryotherapy patients exhibited initially lower, but not statistically significant, bowel function scores, which then improved and approached those of AHS. Both CyberKnife (year 1 mean difference: −26.7, P < 0.001) and Cryotherapy groups (−35.4, P < 0.001) had early lower sexual function scores relative to AHS, but then gradually improved and were not significantly different from AHS by the third year post-treatment. A history of hormonal therapy was associated with a lower sexual function scores relative to those patients who did not receive hormones in both CyberKnife (−18.45, P < 0.01) and Cryotherapy patients (−14.6, P < 0.05).ConclusionsAfter initial lower bowel habits and sexual function scores, CyberKnife or Cryotherapy-treated patients had no significant difference in QoL relative to AHS patients. These results highlight the benefit of CyberKnife and Cryotherapy in the management of organ-confined prostate cancer.

PD36-09 INSTITUTIONAL VOLUME IS ASSOCIATED WITH REDUCED 90 DAY MORTALITY RATES FOR BOTH OPEN AND ROBOTIC RADICAL CYSTECTOMY

The association between PBT and oncological outcomes, as well as OCM was assessed using Cox and logistic regression analyses. Imbalances in clinicopathological features of patients receiving PBT vs. patients not receiving PBT were mitigated using conventional adjusting as well as inverse probability of treatment weighting (IPTW). RESULTS: The final population consisted of 525 patients with a median follow-up of 26 months (IQR: 21-30 months) of whom 275 patients (52.4%) received PBT. The two groups (PBT vs. no PBT) differed significantly with respect to most clinicopathological features including perioperative blood loss (median: 1000ml; IQR: 650-1600ml vs. median: 570ml; IQR: 400-800ml). Independent predictors of receipt of PBT in multivariate logistic regression analysis were sex (odds ratio (OR)1⁄44.66; 95% confidence interval (CI)1⁄4[2.34-9.29]; p<0.001), body mass index (OR1⁄40.92; 95% CI1⁄4[0.87-0.97]; p1⁄40.003), type of urinary diversion (OR1⁄40.40; 95% CI1⁄4[0.22-0.75]; p1⁄40.004), estimated blood loss (OR1⁄41.29; 95% CI1⁄4 [1.21-1.39]; p<0.001), and any complication within 30 days (OR1⁄43.00; 95% CI1⁄4[1.75-5.15]; p<0.001). Unweighted and unadjusted survival analyses revealed a significant increase in cumulative incidences of CSM and OCM in the two groups (p1⁄40.017 and p<0.001, respectively). After IPTW-adjustment, those differences no longer held true. PBT was not associated with RFS (HR1⁄40.92; 95% CI1⁄4[0.53-1.59]; p1⁄40.76), OS (HR1⁄41.07; 95% CI1⁄4[0.56-2.04]; p1⁄40.84), CSM (sub-HR1⁄41.09; 95% CI1⁄4[0.62-1.93]; p1⁄40.76) and OCM (sub-HR1⁄41.02; 95% CI1⁄4[0.27-3.84]; p1⁄40.95) in IPTW-adjusted Cox regression and competing-risks regression analyses. The same held true in conventional multivariate Cox and competing-risks regression analyses, where pathological tumor stage and lymphovascular invasion were the only independent predictors of CSM (HR1⁄43.71, 95% CI1⁄4[2.06-6.68], p<0.001 and HR1⁄42.49, 95% CI1⁄4 [1.43-4.33], p<0.001) aswell as disease recurrence (HR1⁄44.48, 95%CI1⁄4 [2.45-8.16], p<0.001 and HR1⁄42.76, 95% CI1⁄4[1.56-4.87], p<0.001). CONCLUSIONS: This study could not determine an adverse impact of PBT on oncological outcome and overall survival after adjusting for differences in patient characteristics.

MP70-04 3-T MULTIPARAMETRIC MRI CHARACTERISTICS OF PROSTATE CANCER PATIENTS SUSPICIOUS FOR BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOSURGERY.

Source of Funding: This research was made possible through the NIH Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH by the Doris Duke Charitable Foundation (Grant #2014194), the American Association for Dental Research, the Colgate-Palmolive Company, Genentech, and other private donors. For a complete list, visit the foundation website at http://www.fnih. org.

PD56-09 PSA TRENDS FOLLOWING PRIMARY FOCAL CRYOSURGERY FOR EARLY STAGE PROSTATE CANCER

METHODS: Participants were eligible when diagnosed with intermediate risk, unilateral clinically significant localised prostate cancer, fit for either RP or PA. Pre-biopsy mpMRI and targeted biopsy or template guided biopsies were compulsory before randomization to either RP or PA. Target accrual for the feasibility phase was 80 patients over 18 months. Follow-up involved regular PSA measurements and, in the focal therapy arm, mpMRI and targeted biopsies of any suspicious areas. Quality of life data were measured at six weeks and three monthly intervals. RESULTS: The table below summarises recruitment data. Baseline demographics of men randomised to date are Mean age: 66.7yrs (48.4-78.2); BMI: 26.4 (22.0-32.3); PSA: 7.60 (2.5-16.20) and Gleason score: 3+41⁄47 75.6%, 4+31⁄47 24.4%. CONCLUSIONS: A randomised controlled trial of partial ablation of the prostate versus radical treatment with surgery is feasible. The full trial is being developed, and will provide key data to inform men when making the treatment decision for intermediate risk unilateral prostate cancer.

MP70-09 PREDICTORS OF BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOTHERAPY FOR LOCALIZED PROSTATE CANCER: A MULTI-INSTITUTIONAL ANALYTIC COMPARISON OF THE PHOENIX AND STUTTGART CRITERIA

INTRODUCTION AND OBJECTIVES: The Phoenix (PD) and Stuttgart definitions (SD) are used to define biochemical recurrence (BCR) in patients after radiotherapy and High Intensity Focused Ultrasound treatment of organ-confined prostate cancer (PCa) respectively. However, these definitions have also been applied to follow patients who have undergone cryosurgery. We sought to identify predictors of BCR using the PD and SD criteria and evaluate each criterion0s ability to predict biopsy-proven recurrence in primary focal cryosurgery (PFC) patients. METHODS: We performed a retrospective review of patients who underwent PFC at two tertiary care centers. Patients were followed with serial prostate specific antigen (PSA) tests. PSA levels, preand post-PFC biopsy Gleason scores, number of positive cores, and BCR (defined as: PD 1⁄4 [PSA nadir + 2 ng/mL] and SD 1⁄4 [PSA nadir + 1.2 ng/ mL]) were recorded. Patients who experienced BCR were biopsied, monitored carefully or treated at the discretion of the treating urologist. Cox proportional regression and survival analyses were performed to assess time to BCR using the PD and SD criteria. RESULTS: Of 162 patients included [median (range) follow up: 36.6 (2.8-109.4) months] in the study, 64 (39.5%) and 98 (60.5%) experienced BCR based on PD and SD, respectively. On multivariate Cox regression analysis, the number of positive pre-PFC biopsy cores was an independent predictor of both PD (Hazard Ratio [HR]: 1.4, p1⁄40.001) and SD (HR: 1.3, p1⁄40.006) BCRs. Post-PFC PSA nadir was an independent predictor of BCR using the PD (HR: 2.2, p1⁄40.024) but not SD (HR: 1.4, p1⁄40.181) BCR. Survival analysis showed a 3-year BCR free survival of 55% and 36% for PD and SD respectively. Of those biopsied after BCR, 14/26 (53.8%) using the PD and 18/35 (51.4%) using the SD were found to have cancer (57.1% PD and 66.7% SD were clinically significant PCa). CONCLUSIONS: Both the PD and the SD showed about a 50% biopsy-proven rate of recurrence after PFC. The number of positive cores on pretreatment biopsy appears to be a significant predictor of failure after PFC. The ideal definition of BCR after PFC remains to be elucidated.

PD67-05 FACILITY VOLUME AND TYPE IS ASSOCIATED WITH RECEIPT OF CONTINENT DIVERSION FOR BOTH OPEN AND ROBOTIC RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: Continent urinary diversion (CUD) can offer improved quality of life in select patients follow in radical cystectomy (RC). We aim to evaluate the rate of receipt of CUD in robotic assisted RC (RARC) and open RC (ORC) based on hospital volume and facility type in the National Cancer Data Base. METHODS: We divided all cystectomy cases into volume categories (defined as: 1-2.9, 3-4.9, 5-9.9, 10-19.9 and 20+ cystectomies/ year) and facility type (academic/research (AR), comprehensive community (CC) and other), type of surgery (ORC or RARC) to assess the patterns in the rate of receipt of CUD. To assess the relationship between facility characteristics and receipt of CUD, chi-square was used. Univariate and multivariable logistic regression models for CUD rates were used to adjust for patient, tumor and facility characteristics. RESULTS: 16,923 RC cases were identified (ORC 1⁄4 13,236, RARC1⁄43,687). Overall, 5.7% of ORC (754) and 7.1% of RARC (261) received CUD (p1⁄40.003). RARC had higher rates of receiving CUD compared to ORC in all volume categories except for the highest volume centers (10.2% vs 9.7%). Rates of receipt of CUD increased with increasing RC volume centers (p1⁄40.01); in the ORC group (2.8 vs. 10.2%), and in the RARC group by (5.7% vs. 9.7%; p for interaction1⁄40.10). In adjusted models, center volume remained a highly significant predictor of CUD receipt (p<0.001). Rates of receipt of CUD were higher in RARC vs. ORC in CC and other facility types, but were equal in AR facilities. The difference in the rate of CUD receipt between facility types was significant for ORC (p1⁄40.001) but not for RARC (p1⁄40.09). CUD receipt was observed to decrease linearly over time in both ORC (6.9% in 2010 vs. 4.7 in 2013; p1⁄40.001) and RARC (9.4% in 2010 vs. 6.0% in 2013; p1⁄40.06). CONCLUSIONS: Increasing facility cystectomy volume was associated with increased rates of receipt of CUD in both open and robotic cystectomy while facility type was only significant for open surgeries. The overall rate of receiving CUD was higher in RARC versus ORC surgeries but the overall rate of patients receiving continent diversions remains low and may be decreasing.