Stephen Lang

Progression, interobserver agreement, and malignancy rate in complex renal cysts (≥Bosniak category IIF)

OBJECTIVE The objective of this study was to assess interobserver agreement, clinicopathologic correlation, and radiologic follow-up progression of complex cystic renal masses. PATIENTS AND METHODS The medical records of 143 patients with 154 complex cystic renal masses were retrieved. Primary outcomes were interobserver agreement between the radiologists, and malignancy rates following surgical extirpation with or without follow-up in Bosniak IIF, III, and IV categories. Secondary outcomes were correlation between histology and degree of enhancement on contrast-enhanced computed tomography scans and survival analysis of patients with or without surgical intervention using the Kaplan-Meier analysis. RESULTS The overall malignancy rate in patients who had surgery was 74.5% (29/39). Of 27 confirmed renal cell carcinoma on final histology, 9 were papillary renal cell carcinoma (incidence 33.3%). Assessment of interobserver agreement yielded a weighted kappa statistic value of 0.69 (95% confidence interval 0.56-0.82, P<0.0001). Radiologic progression rate of Bosniak IIF cysts over median follow-up of 18.5 months was 13% (10/78). There was no statistically significant difference between progression rate and regression rate of IIF cysts (13.8% vs. 11.5%) over the period of 24 months of follow-up. Most of the progression in complex cystic renal masses was seen in the first 2 years of follow-up. The malignancy rate on radiologic progression was 87.5% (8/9) and 75% (6/8) in Bosniak IIF and III cystic masses, respectively. The malignancy rate in Bosniak III cyst was 50% (4/8) without a period of initial observation or follow-up. CONCLUSIONS A good degree of agreement exists between radiologists in classifying complex renal masses. Malignancy rate is considerably high in Bosniak IIF when they exhibit radiologic progression on systematic follow-up.

Detection and characterisation of biopsy tissue using quantitative optical coherence elastography (OCE) in men with suspected prostate cancer

We present first quantitative three-dimensional (3D) data sets recorded using optical coherence elastography (OCE) for the diagnosis and detection of prostate cancer (PCa). 120 transrectal ultrasound guided prostate biopsy specimens from 10 men suspected with prostate cancer were imaged using OCE. 3D quantitative mechanical assessment of biopsy specimens obtained in kilopascals (kPa) at an interval of 40 µm was compared with histopathology. Sensitivity, specificity, and positive and negative predictive values were calculated for OCE in comparison to histopathology. The results show OCE imaging could reliably differentiate between benign prostate tissue, acinar atypical hyperplasia, prostatic intraepithelial neoplasia and malignant PCa. The sensitivity and specificity of OCE for the detection of prostate cancer was 0.98 and 0.91 with AUC > 0.99. Quantitative 3D OCE based on the assessment of mechanical properties of tissues can reliably differentiate prostate tissue specimen in an ex-vivo setting. This is a promising imaging modality for characterising different grades of cancers.

Carcinoma In Situ Is Significantly Underdetected by Prenephroureterectomy Ureteroscopy in the Management of Upper Tract Urothelial Cancers

Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general. Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS). Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen (P = 0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance (P = 0.004). Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.

Prostatic adenocarcinoma metastatic to the palatine tonsil: a case report

A case of prostatic adenocarcinoma presenting with dysphagia due to a tonsillar metastasis is described. Details of the clinical history, histopathological and autopsy findings are presented. A review of the literature suggests that this is only the second description of such an occurrence.

Recurrent dermatomyositis manifesting as a sign of recurrent transitional cell carcinoma of urinary bladder: Long-term survival

The association between urological malignancies and paraneoplastic syndromes has been well documented. We report a case of recurrent dermatomyositis manifesting as a sign of metastatic recurrence of non-muscle-invasive transitional cell carcinoma of the bladder, a relationship which has only been referred to in a few reports. The case highlights a few important clinical challenges; firstly, the importance of thorough investigation for underlying malignancy in patients with dermatomyositis, as successful treatment of such malignancy can lead to resolution of paraneoplastic symptoms, and secondly, a high index of suspicion of recurrence in cases where paraneoplastic manifestations recur. Metastatic pulmonary recurrence without local evidence of disease at a follow-up of 4 years makes this case unique. Moreover, in the light of our experience and reported literature, a framework is suggested to approach such a diagnostic dilemma in the future. Description of the case will guide clinicians in the future, in case they encounter such an unusual clinical scenario. This could also serve as a hypothesis-generating source for designing future research as well.

Second harmonic generation (SHG) imaging of cancer heterogeneity in ultrasound guided biopsies of prostate in men suspected with prostate cancer.

Prostate cancer is a multifocal disease with characteristic heterogeneity and foci that can range from low grade indolent to aggressive disease. The latter is characterised by the well-established histopathological Gleason grading system used in the current clinical care. Nevertheless, a large discrepancy exists on initial biopsy and after the final radical prostatectomy. Moreover, there is no reliable imaging modality to study these foci, in particular at the level of the cells and surrounding matrix. Extracellular matrix (ECM) remodelling is significant in cancer progression with collagen as the dominant structural component providing mechanical strength and flexibility of tissue. In this study, the collagen assembly in prostate tissue was investigated with second harmonic generation (SHG) microscopy: malignant foci demonstrated a reticular pattern, with a typical collagen pattern for each Gleason score. The orientation of collagen for each biopsy was computed by applying a ratio of the anisotropic and isotropic collagen fibres. This value was found to be distinct for each Gleason score. The findings suggest that this approach can not only be used to detect prostate cancer, but also can act as a potential biomarker for cancer aggressiveness.

Early oncological and functional outcomes following radical treatment of high-risk prostate cancer in men older than 70 years: A prospective longitudinal study

BACKGROUND Assess early oncological and functional outcomes following radical treatment of men with high-risk prostate cancer and aged more than 70 years. PATIENTS AND METHODS A total of 335 men with high-risk prostate cancer (prostate-specific antigen ≥20ng/ml or biopsy Gleason score 8 to 10 or≥cT2c) received radical treatment between 2007 and 2014. Men were identified from comprehensive clinical databases hosted at a tertiary cancer center in the UK. The data included basic demographics, and follow-up on functional and oncological outcomes using validated patient-reported outcome questionnaires. Univariate and multivariate analyses were used. RESULTS In all, 117 patients received radical radiotherapy (RT) alone, 167 patients received neoadjuvant hormone therapy and RT, and 54 patients underwent radical prostatectomy with extended lymph node dissection. Mean age was 72.8, standard deviation (SD) = 2.1, mean follow-up of 40.9 months, SD = 25.5 months. Patients who underwent laparoscopic prostatectomy = 24 (44.4%) had positive surgical margins, and mean lymph nodes dissected were 18.7, SD = 6.7. Further, 5 men experienced postoperative complications in the form of pseudoaneurism of internal iliac branch, leg ischemia, high CO2 retention, and 2 men experienced sepsis. Incidence of biochemical recurrence was significantly lower at 16.7% in the surgery group, compared with RT 51.3% and RT and hormone therapy 30.5%, and Kaplan-Meier analysis P<0.001 over 3 years of follow-up CONCLUSION Radical surgery with extended lymph nodes dissection appears to have good short-term oncological and functional outcomes compared with RT with or without hormones in high-risk men older than 70 years of age. Based on these findings, treatment decisions and surgical therapy should be considered on individual basis in older men with high-risk disease.

Videotaping of surgical procedures and outcomes following extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer

Video‐recording of emerging minimally invasive surgical procedures is likely to become an integral component of patient record‐keeping in the future for prostate cancer treatment. No prior work has shown the impact of videotaping of laparoscopic prostatectomy on patient outcomes. Our aim was to determine correlation between independent peer review of videotaping quality scores of extraperitoneal laparoscopic prostatectomy (ELRP) with complications, re‐admissions, functional, and early oncological outcomes.

Quantitative transrectal shear wave elastography undergoing salvage extraperitoneal laparoscopic radical prostatectomy following failed radiotherapy

BackgroundTo evaluate pre-surgical quantitative transrectal shear wave elastography (SWE) in the detection and characterisation of radioresistant prostate cancer.MethodsTwelve men with recurrent prostate cancer following external beam radiotherapy were included in a prospective protocol-driven study. All underwent MR imaging and quantitative shear wave elastographic assessment of recurrent disease prior to salvage laparoscopic radical prostatectomy procedures. Images were used to construct 3D mold printing and histopathological processing of surgical specimen. Statistical analyses including ROC were generated using software programmes.ResultsThere were 48 cancer foci identified on final histopathology using patient-specific mold-based approach in 12 patients. Mean number of lesion was 3.4 (range 2–4). Quantitative transrectal SWE showed a sensitivity and specificity 0.77 (95% CI 0.627–0.880) and 0.82 (95% CI 0.642–0.942), respectively. The diagnostic accuracy increased with increasing size of the lesions with overall AUC of 0.89.ConclusionsIn our series, quantitative transrectal SWE showed a good diagnostic accuracy in the detection and characterisation of recurrent prostate cancer following failed radiotherapy treatment. These findings may help in targeting biopsies or future focal treatment options.

Quantitative assessment of the mechanical properties of prostate tissue with optical coherence elastography

Prostate cancer (PCa) is a heterogeneous disease with multifocal origin. In current clinical care, the Gleason scoring system is the well-established diagnosis by microscopic evaluation of the tissue from trans-rectal ultrasound (TRUS) guided biopsies. Nevertheless, the sensitivity and specificity in detecting PCa can range from 40 to 50% for conventional TRUS B-mode imaging. Tissue elasticity is associated with the disease progression and elastography technique has recently shown promise in aiding PCa diagnosis. However, many cancer foci in the prostate gland has very small size less than 1 mm and those detected by medical elastography were larger than 2 mm. Hereby, we introduce optical coherence elastography (OCE) to quantify the prostate stiffness with high resolution in the magnitude of 10 µm. Following our feasibility study of 10 patients reported previously, we recruited 60 more patients undergoing 12-core TRUS guided biopsies for suspected PCa with a total of 720 biopsies. The stiffness of cancer tissue was approximately 57.63% higher than that of benign ones. Using histology as reference standard and cut-off threshold of 600kPa, the data analysis showed sensitivity and specificity of 89.6% and 99.8% respectively. The method also demonstrated potential in characterising different grades of PCa based on the change of tissue morphology and quantitative mechanical properties. In conclusion, quantitative OCE can be a reliable technique to identify PCa lesion and differentiate indolent from aggressive cancer.