Sabina Sevcenco

Utility and limitations of 3-Tesla diffusion-weighted magnetic resonance imaging for differentiation of renal tumors

OBJECTIVE To investigate utility and limitations of 3-Tesla diffusion-weighted (DW) magnetic resonance imaging (MRI) for differentiation of benign versus malignant renal lesions and renal cell carcinoma (RCC) subtypes. MATERIALS AND METHODS Sixty patients with 71 renal lesions underwent 3 Tesla DW-MRI of the kidney before diagnostic tissue confirmation. The images were retrospectively evaluated blinded to histology. Single-shot echo-planar imaging was used as the DW imaging technique. Apparent diffusion coefficient (ADC) values were measured and compared with histopathological characteristics. RESULTS There were 54 malignant and 17 benign lesions, 46 lesions being small renal masses ≤ 4 cm. Papillary RCC lesions had lower ADC values (p=0.029) than other RCC subtypes (clear cell or chromophobe). Diagnostic accuracy of DW-MRI for differentiation of papillary from non-papillary RCC was 70.3% resulting in a sensitivity and specificity of 64.3% (95% CI, 35.1-87.2) and 77.1 (95% CI, 59.9-89.6%). Accuracy increased to 83.7% in small renal masses (≤ 4 cm diameter) and sensitivity and specificity were 75.0% and 88.5%, respectively. The ADC values did not differ significantly between benign and malignant renal lesions (p=0.45). CONCLUSIONS DW-MRI seems to distinguish between papillary and other subtypes of RCCs especially in small renal masses but could not differentiate between benign and malignant renal lesions. Therefore, the use of DW-MRI for preoperative differentiation of renal lesions is limited.

Prospective evaluation of diffusion-weighted MRI of the bladder as a biomarker for prediction of bladder cancer aggressiveness.

OBJECTIVES To prospectively test the utility of diffusion-weighted magnetic resonance imaging (DW-MRI) for bladder cancer (BCA) staging and grading. METHODS AND MATERIALS We prospectively enrolled 51 consecutive patients (median age = 64 y, range: 30-90y) with suspected BCA with or without gross hematuria who received 3-T DW-MRI before transurethral resection of the bladder. Parametric apparent diffusion coefficient (ADC) maps were automatically calculated from DW-MRI. ADC values (given in × 10(-3)mm(2)/s) of bladder lesions were independently measured by 2 radiologists blinded to histopathology. Comparisons of ADC values with histopathologic features were performed using unpaired t tests. Diagnostic performance was calculated by means of receiver operating characteristics (ROC) statistics. RESULTS We excluded 8 patients: 1 presenting with metastatic melanoma to the bladder, 1 who had an incomplete examination, and 6 without BCA. In the 43 remaining patients (median age = 68 y, range: 41-85 y), the ADC values were lower in high-grade (n = 19, ADC = 0.787) compared with low-grade (n = 24, ADC = 1.233) tumors (P<0.0001) and in muscle-invasive tumors (n = 10, ADC = 0.759) compared with non-muscle-invasive tumors (n = 33, ADC = 1.120, P = 0.0004). The area under the ROC curve was 0.884 for prediction of muscle invasion and 0.906 for prediction of high grade by using ADC values. Rule-in ADC criteria for high-grade lesions and rule-out ADC criteria for muscle invasion were identified by ROC analysis. CONCLUSIONS ADC measurements obtained by DW-MRI are a promising imaging biomarker for prediction of BCA stage and grade providing high sensitivity and specificity. Further studies are necessary to establish the value of this test in guiding decision making in clinical practice.

Quantitative apparent diffusion coefficient measurements obtained by 3-Tesla MRI are correlated with biomarkers of bladder cancer proliferative activity.

Purpose To investigate the association between Apparent Diffusion Coefficient (ADC) values and cell cycle and proliferative biomarkers (p53, p21, Ki67,) in order to establish its potential role as a noninvasive biomarker for prediction of cell cycle, proliferative activity and biological aggressiveness in bladder cancer. Materials and Methods Patients with bladder cancer who underwent 3,0 Tesla DW-MRI of the bladder before TUR-B or radical cystectomy were eligible for this prospective IRB-approved study. Histological specimen were immunohistochemically stained for the following markers: p53, p21 and ki67. Two board-certified uropathologists reviewed the specimens blinded to DW-MRI results. Histological grade and T-stage were classified according to the WHO 2004 and the 2009 TNM classification, respectively. Nonparametric univariate and multivariate statistics including correlation, logistic regression and ROC analysis were applied. Results Muscle invasive bladder cancer was histologically confirmed in 10 out of 41 patients. All examined tissue biomarkers were significantly correlated with ADC values (p<0.05, respectively). Based on multivariate analysis, p53 and ADC are both independent prognostic factors for muscle invasiveness of bladder cancer (>/ = T2). (p = 0.013 and p = 0.018). Conclusion ADC values are associated with cell cycle and proliferative biomarkers and do thereby reflect invasive and proliferative potential in bladder cancer. ADC and p53 are both independent prognostic factors for muscle invasiveness in bladder cancer.

Predictive Power of Objectivation of Phimosis Grade on Outcomes of Topical 0.1% Betamethasone Treatment of Phimosis

OBJECTIVE To evaluate the predictive power of the objectivation of the phimosis grade according to the classification defined by Kikiros and Woodward, with regard to the expected efficacy of 0.1% betamethasone cream as a treatment option. METHODS From October 2010 to May 2011, a total of 55 boys (aged <10 years) were treated for phimosis at our department. An assessment of the category of phimosis and the retractability of the foreskin, according to the classification of Kikiros and Woodward, was performed. The proposed treatment options included complete circumcision or topical treatment with steroid cream (0.1% betamethasone-17-valerate). RESULTS Of the 55 patients, 19 (34.5%) underwent conventional circumcision, and 36 (65.5%) were treated with an 8-week course of topical steroid cream. The mean age was 3.9 years (range 0.6-10). Grade 1, 2, 3, 4, and 5 phimosis was seen in 1 (2.8%), 4 (11.1%), 8 (22.2%), 16 (44.4%), and 7 (19.4%) of the cases in the topical steroid cream group, respectively. The success rate for the topical steroid cream was 69.4% and 63.9% at 3 and 8.3 months, respectively. The objectivation of the phimosis grade did not predict the outcome (P > .05). No side effects were associated with the topical steroid treatment. CONCLUSION The pretreatment classification of phimosis did not allow the prediction of success with the topical steroid treatment. We believe that topical steroid therapy with foreskin retraction and daily cleansing is a valid therapy modality that should be offered before any surgical intervention, regardless of the degree of phimosis.

Inter-observer variation and diagnostic efficacy of apparent diffusion coefficient (ADC) measurements obtained by diffusion-weighted imaging (DWI) in small renal masses

Background Diffusion-weighted imaging (DWI) is increasingly used to diagnose renal lesion subtypes. Especially in small renal masses, identification of less aggressive tumor types is of clinical interest, as active surveillance strategies can be applied. Purpose To evaluate the inter-observer variation and diagnostic efficacy of apparent diffusion coefficient (ADC) measurements obtained by DWI in small renal masses ≤4 cm (SRM). Material and Methods This retrospective IRB-approved study included 39 patients (46 SRM: 12 benign, 34 malignant). All underwent a 3 T DWI of SRM prior to surgery. Two radiologists independently analyzed all imaging data by three measurements. Limits of agreement, intraclass correlation coefficients (ICC), group comparisons by t-tests, and ROC analysis were performed. Results Reliability of ADC measurements was very high with an ICC of >0.9 for both observers. Inter-rater reliability was high with an ICC of 0.82. Limits of agreement for average ADC values between both observers were −23.5% to 38.3% with a mean difference of 7.5% between both observers. No significant differences were found between benign and malignant lesions (P value Observer 1: 0.362, Observer 2: 0.622). Papillary carcinoma showed lower ADC values compared to non-papillary carcinoma (P value Observer 1: 0.008, Observer 2: 0.012). Consequently, ROC analysis revealed a significant (P < 0.001, respectively) area under the ROC curve of 0.853 (Observer 1) and 0.837 (Observer 2) without significant differences between both readers (P = 0.772). Conclusion ADC measurements of SRM at 3 T show a high reproducibility and differentiate papillary from non-papillary carcinoma subtypes. However, measurement variability may limit the application of fixed ADC thresholds for lesion diagnosis.

Bringing excellence into urology: How to improve the future training of residents?

Abstract The problem: The demographic development of society leads to an increased demand for physicians. Particularly in the surgical disciplines, there is a noticeably declining interest among graduates from medical schools worldwide. For reasons discussed in detail, this applies especially to urology. Solutions: We indicate possibilities on how to counteract this trend, by improving the training for urology residents. Whereas some major changes for the better have already been introduced into the curricula in some countries, others will have to be further specified in the future. This article gives an overview of the requirements of a specific training programme, from a planning phase to its certification. Aspects such as the selection of candidates, the goals of a good training programme, and an implementation strategy are presented. Essential elements of a urology resident programme for effective coaching, improving medical skills (e.g. in surgical laboratories), knowledge revision, progress evaluation, and retrospection are discussed critically, giving an understanding of the crucial requirements of a good and attractive education in urology. Conclusion: A structured and well organised training programme might attract additional medical students towards urology and contribute significantly to the further development of the speciality. This can be seen as an initiative to counteract the decline of urology as an attractive field of interest to upcoming generations of physicians, and therefore to ensure urological care of the highest quality that patients deserve.

The cumulative analgesic consumption score (CACS): evaluation of a new score to describe postsurgical analgesic consumption as a surrogate parameter for postoperative pain and invasiveness of surgical procedures

OBJECTIVE To validate and evaluate the applicability of a new score to describe postsurgical analgesic consumption in urological and surgical patients across different categories of pain medications and the invasiveness of medical interventions. MATERIALS AND METHODS The cumulative analgesic consumption score (CACS) was determined for two cohorts of patients split into three groups with surgeries involving clinically distinct levels of invasiveness (n = 2 x 60). Nonparametric statistical analyses were performed to determine differences between the CACS among the different groups and to assess the correlation between CACS and numeric rating scale (NRS) values for pain intensity. RESULTS The score was determined for postoperative days 1 and 2 and revealed median scores of 0 (0-11), 3 (0-22) and 10 (6-17) for UA (urological patients from group A), UB (group B) and UC (group C), respectively, and 4 (0-20), 8 (0-38) and 17 (7-68) for SA (surgical patients from group A, SB (group B) and SC (group C), respectively. CACS enabled reliable differentiation between groups involving different levels of invasiveness (p < 0.001). CACS and peak NRS values showed variable degrees of correlation, as expressed by levels of significance ranging from p < 0.001 to p = 0.34 (NS). CONCLUSIONS The CACS is a valid and easily applicable tool to describe postsurgical analgesic consumption in urological and surgical patients. It can be used as a surrogate parameter to assess postsurgical pain and the invasiveness of surgical procedures. These aspects may be measured to compare surgical procedures, in both clinical trials and clinical practice settings.

In-bore 3.0-T Magnetic Resonance Imaging-guided Transrectal Targeted Prostate Biopsy in a Repeat Biopsy Population: Diagnostic Performance, Complications, and Learning Curve

OBJECTIVE To evaluate the diagnostic performance and complication rate of the in-bore magnetic resonance imaging-guided transrectal targeted prostate biopsy (MRGB) in a repeat biopsy population on the basis of a nearly 4-year learning curve (2014-2017). MATERIALS AND METHODS A total of 142 consecutive males with previous biopsies and persistent suspicion of prostate cancer (PCa) due to high prostate-specific antigen level initially underwent MRGB in the case of prostate imaging reporting and data system (PI-RADS) 3-5 lesions. Cancer detection rate (CDR), number and length of cores, biopsy time, operator experience, complications, and prediction of clinically significant (cs) PCa (Gleason score ≥7) were investigated. RESULTS PCa was found in 57% of patients. CDR in PI-RADS 3, 4, and 5 lesions were 46%, 52%, and 74%, respectively. csPCa was found in 9%, 25%, and 48% of patients. In univariate analysis the PI-RADS score (P = .0067) was a significant predictor of csPCa. In the multivariate logistic regression, age (P = .0007), number of previous biopsies (P = .0236), and prostate-specific antigen density (P = .0250) were significant predictors of csPCa. Location and size of the index lesion, number and length of cores obtained, and operator experience did not affect CDR. Concerning learning curve, biopsy time and number of cores obtained improved significantly after 10 procedures. Complications requiring medical intervention were seen in 6% (infections 2%). CONCLUSION In a re-biopsy setting the MRGB showed sufficient diagnostic performance in detecting csPCa in PI-RADS 3-5 lesions, with low complication rate. The skill of performing biopsy is quickly acquired, and location of index lesion did not have an impact on CDR.

Solitary Osteoclast-like Giant Cell Tumor of the Kidney: A Case Report

Osteoclast-like giant cell tumors are very uncommon and originate in osseous and tendinous tissues. However, they are also very rarely found in visceral organs. The kidney is extremely rarely affected by this tumor entity; usually osteoclast-like giant cell tumors are associated with papillary renal cell carcinoma. We present the third case in the literature of a solitary osteoclast-like giant cell tumor in the kidney of an 89-year-old man and give a short overview of the current literature.