Yasukazu Nakanishi

High Diagnostic Ability of Multiparametric Magnetic Resonance Imaging to Detect Anterior Prostate Cancer Missed by Transrectal 12-Core Biopsy

PURPOSE We clarified the diagnostic ability of multiparametric magnetic resonance imaging to reveal anterior cancer missed by transrectal 12-core prostate biopsy based on the results of 3-dimensional 26-core prostate biopsy, which is a combination of transrectal 12-core and transperineal 14-core biopsies. MATERIALS AND METHODS The study population consisted of 324 patients who prospectively underwent prebiopsy multiparametric magnetic resonance imaging and then 3-dimensional 26-core prostate biopsy at a single institution. We defined transrectal 12-core negative cancer as cancer detected by transperineal 14-core but not transrectal 12-core prostate biopsy. We focused on cancer in the anterior region. Any findings suspicious for malignancy in the region anterior to the urethra on multiparametric magnetic resonance imaging were defined as an anterior lesion on imaging. Significant cancer was defined as a biopsy Gleason score of 4 + 3 or greater, a greater than 20% positive core and/or a maximum cancer length of 5 mm or greater. Associations between an anterior lesion on imaging and transrectal 12-core negative cancer were investigated. RESULTS The overall cancer detection rate on 3-dimensional 26-core prostate biopsy was 39% (128 of 324 cases), of which 28% (36 of 128) were transrectal 12-core negative cancers. An anterior lesion on prebiopsy multiparametric magnetic resonance imaging was identified in 20% of men overall (65 of 324). Of men with and without an anterior lesion on imaging 40% (26 of 65) and 3.8% (10 of 259), respectively, had transrectal 12-core negative cancer. Significant transrectal 12-core negative cancer was observed in 0.4% (1 of 259 men) without an anterior lesion on imaging. Prebiopsy multiparametric magnetic resonance imaging revealed an anterior lesion in 92% of cases (11 of 12) of significant transrectal 12-core negative cancer. CONCLUSIONS Prebiopsy multiparametric magnetic resonance imaging has the potential to efficiently select men who could advantageously undergo anterior samplings, in addition to transrectal 12-core prostate biopsy.

Sarcopenia as a prognostic biomarker of advanced urothelial carcinoma.

Objectives Sarcopenia, a novel concept reflecting the degenerative loss of skeletal muscle mass, is an objective indicator of cancer cachexia. We investigated its role as a prognostic biomarker in advanced urothelial carcinoma (UC) patients. Methods This retrospective study consisted of 88 UC patients with cT4 and/or metastases to lymph nodes/distant organs. Skeletal muscle index (SMI), an indicator of whole-body muscle mass, was measured from computed tomography (CT) images at the diagnosis. Sarcopenia was defined as SMIs of <43 cm2/m2 for males with body mass index (BMI) <25 cm2/m2, <53 cm2/m2 for males with BMI ≥25 cm2/m2, and <41 cm2/m2 for females. Predictors of overall survival (OS) were examined using Cox proportional hazard models. Results Sixty-seven patients (76%) died during the median follow-up of 13 months. The median OS rate was 13 months. Multivariate analysis revealed that SMI was a significant and independent predictor of shorter OS (hazard ratio (HR) 0.90, P <0.001). In the present cohort, 53 (60%) were diagnosed with sarcopenia. The median OS rates were 11 and 31 months for sarcopenic and non-sarcopenic patients, respectively (P <0.001). On multivariate analysis, sarcopenia was a significant and independent predictor of shorter OS (HR 3.36, P <0.001), along with higher C-reactive protein (CRP) (P = 0.001), upper urinary tract cancer (P = 0.007), higher lactate dehydrogenase (LDH) (P = 0.047), and higher alkaline phosphatase (ALP) (P = 0.048). Conclusion Sarcopenia, which is readily evaluated on routine CT scans, is a useful prognostic biomarker of advanced UC. Non-sarcopenic patients can expect long-term survival. Evaluating sarcopenia can be helpful for decision-making processes in the management of advanced UC patients.

Prognostic Significance of Sarcopenia in Patients with Metastatic Renal Cell Carcinoma

PURPOSE Sarcopenia, a novel concept reflecting the degenerative loss of skeletal muscle mass, is a critical physiological change during the development of cancer cachexia. We retrospectively investigated the prognostic role of sarcopenia in patients with metastatic renal cell carcinoma. MATERIALS AND METHODS Skeletal muscle index was calculated using computerized tomography performed at the diagnosis of metastatic renal cell carcinoma. Sarcopenia was defined as skeletal muscle index less than 43 cm(2)/m(2) for males with a body mass index less than 25 kg/m(2), less than 53 cm(2)/m(2) for males with a body mass index 25 kg/m(2) or greater, and less than 41 cm(2)/m(2) for females. The relationship between sarcopenia and overall survival was assessed in 92 patients with metastatic renal cell carcinoma using Cox proportional hazards models. The predictive accuracy of these models was evaluated using the c-index. RESULTS A total of 63 (68%) patients were classified as having sarcopenia and 52 (57%) died (median overall survival 27 months) during followup (median 19 months). A multivariate analysis identified sarcopenia as a significant and independent predictor of overall survival (HR 2.58, p = 0.015), along with prior nephrectomy (p <0.001), number of metastatic sites (p = 0.017), corrected calcium (p = 0.026) and lactate dehydrogenase (p = 0.006). The 3-year overall survival rates were 31% and 73% for sarcopenic and nonsarcopenic cases, respectively (p <0.001). The integration of sarcopenia into the Memorial Sloan Kettering Cancer Center risk model improved the c-index from 0.726 to 0.758 (addition of sarcopenia to the original model) and 0.755 (substitution of sarcopenia for Karnofsky performance status). CONCLUSIONS Sarcopenia is a significant prognostic factor in metastatic renal cell carcinoma.

Risk stratification for bladder recurrence of upper urinary tract urothelial carcinoma after radical nephroureterectomy

To identify risk factors and develop a model for predicting recurrence of upper urinary tract urothelial carcinoma (UTUC) in the bladder in patients without a history of bladder cancer after radical nephroureterectomy (RNU).

Head-mounted display for a personal integrated image monitoring system: ureteral stent placement.

The personal head-mounted display (HMD) has emerged as a novel image monitoring system. We present here the application of a high-definition organic electroluminescent binocular HMD in ureteral stent placement. Our HMD system displayed multiple forms of information such as integrated, sharp, high-contrast images using a four-split screen or a picture-in-picture technique both seamlessly and synchronously. When both the operator and the assistant wore an HMD, they could continuously and simultaneously monitor the cystoscopic and fluoroscopic images in an ergonomically natural position. Furthermore, each participant was able to modulate the displayed images depending on the procedure. In all five cases, both the operator and the assistant successfully used this system with no unfavorable event. No participants experienced any HMD wear-related adverse effects. We therefore believe this HMD system might be potentially beneficial during ureteral stent placement procedures. Furthermore, it is compact, easily introduced and affordable.

Clinical Application of a Modern High-Definition Head-Mounted Display in Sonography

Because of the remarkably improved image quality and wearability of modern head‐mounted displays, a monitoring system using a head‐mounted display rather than a fixed‐site monitor for sonographic scanning has the potential to improve the diagnostic performance and lessen the examiners physical burden during a sonographic examination. In a preclinical setting, 2 head‐mounted displays, the HMZ‐T2 (Sony Corporation, Tokyo, Japan) and the Wrap1200 (Vuzix Corporation, Rochester, NY), were found to be applicable to sonography. In a clinical setting, the feasibility of the HMZ‐T2 was shown by its good image quality and acceptable wearability. This modern device is appropriate for clinical use in sonography.

Postoperative Changes in Skeletal Muscle Mass Predict Survival of Patients With Metastatic Renal Cell Carcinoma Undergoing Cytoreductive Nephrectomy

Micro‐Abstract We investigated the prognostic effect of postoperative changes in skeletal muscle mass in 37 patients with metastatic renal cell carcinoma undergoing cytoreductive nephrectomy. Postoperative changes in the skeletal muscle mass, measured on computed tomography images, were significantly associated with overall survival. Thus, postoperative changes in skeletal muscle mass could be a novel biomarker serving as a useful surrogate for prognosis. Background: Sarcopenia, or the degenerative loss of skeletal muscle mass, develops as a consequence of cancer–host interactions, including systemic inflammation and poor nutritional status, and is associated with a poor prognosis in patients with metastatic renal cell carcinoma (mRCC). We explored whether postoperative changes in skeletal muscle mass after cytoreductive nephrectomy (CN) can predict the prognosis of patients with mRCC. Patients and Methods: The present retrospective study included 37 mRCC patients undergoing CN at a single cancer center. The skeletal muscle index (SMI) was calculated by measuring the skeletal muscle areas at the third lumbar vertebra level on computed tomography images taken ≤ 1 month before and 5 to 6 months after CN. The percentage of change in the SMI (&Dgr;SMI) was calculated as [(postoperative SMI − preoperative SMI)/preoperative SMI] × 100, and the association with overall survival (OS) was analyzed. Results: During the follow‐up period (median, 61 months for survivors), 16 patients (43%) died for a 3‐year OS rate of 63%. The &Dgr;SMI was significantly associated with OS (hazard ratio, 0.92; P < .001). When the patients were categorized into 3 groups according to the &Dgr;SMI (decreased, 12 patients with &Dgr;SMI ≤ −5; stabilized, 15 patients with &Dgr;SMI < 5; and increased, 10 patients with &Dgr;SMI ≥ 5), the OS curves were distinctly separate, with a 3‐year OS rate of 19%, 76%, and 100%, respectively (P < .001). Conclusion: Postoperative changes in the SMI after CN predict OS for patients with mRCC. SMI kinetics is a novel biomarker that can serve as a useful surrogate for the prognosis of patients with mRCC undergoing CN.

Pre-operative Risk Stratification for Cancer-specific Survival in Patients with Renal Cell Carcinoma with Venous Involvement Who Underwent Nephrectomy

OBJECTIVE The aim of this study is to identify the pre-operative prognostic factors and create a risk stratification model for patients with renal cell carcinoma with extension into the renal vein or inferior vena cava. METHODS The study cohort included 61 patients with renal cell carcinoma extending into the renal vein or inferior vena cava that underwent operations between 1993 and 2012. Cancer-specific survival rates were estimated, and univariate and multivariate analyses were carried out to determine the prognostic factors. A simple risk stratification model was developed for these patients. RESULTS The median follow-up period of the current patient cohort was 33.7 months. Their 1, 3 and 5-year cancer-specific survival were 89, 70 and 65%, respectively. On multivariate analysis, the level of tumor thrombus extension (extension into the supradiaphragm), presence of distant metastasis and elevation of lactate dehydrogenase and C-reactive protein were independent negative prognostic factors for cancer-specific survival. Cancer-specific survival rates were clearly discriminated by the stratification according to the scoring model (P < 0.001). The concordance index of the new model was 0.80. CONCLUSIONS We demonstrated a simple risk stratification model with four pre-operative independent prognostic factors for patients with renal cell carcinoma with venous involvement. This may be a useful decision-making model in the management of such patients.

New head-mounted display system applied to endoscopic management of upper urinary tract carcinomas

PURPOSE We tested a new head-mounted display (HMD) system for surgery on the upper urinary tract. SURGICAL TECHNIQUE Four women and one man with abnormal findings in the renal pelvis on computed tomography and magnetic resonance imaging underwent surgery using this new system. A high definition HMD (Sony, Tokyo, Japan) is connected to a flexible ureteroscope (Olympus, Tokyo, Japan) and the images from the ureteroscope are delivered simultaneously to various participants wearing HMDs. Furthermore, various information in addition to that available through the endoscope, such as the narrow band image, the fluoroscope, input from a video camera mounted on the lead surgeons HMD and the vital monitors can be viewed on each HMD. RESULTS Median operative duration and anesthesia time were 53 and 111 minutes, respectively. The ureteroscopic procedures were successfully performed in all cases. There were no notable negative outcomes or incidents (Clavien-Dindo grade ≥ 1). CONCLUSION The HMD system offers simultaneous, high-quality magnified imagery in front of the eyes, regardless of head position, to those participating in the endoscopic procedures. This affordable display system also provides various forms of information related to examinations and operations while allowing direct vision and navigated vision.

Significance of Positive Urine Cytology on Progression and Cancer-Specific Mortality of Non–Muscle-Invasive Bladder Cancer

BACKGROUND Positive results from voided urine cytology (VUC) indicate the fragility of the intercellular adhesion of bladder cancer cells, a critical biological process for invasion and metastasis, along with the presence of atypical cells. Few studies have focused on the prognostic role of VUC in non-muscle-invasive bladder cancer (NMIBC). METHODS Between 2000 and 2010, 326 patients diagnosed pathologically with Ta or T1 bladder urothelial carcinoma underwent 597 transurethral resections of bladder tumor (TURBTs). Clinicopathological data were prospectively collected at each TURBT. Reports of cells of class IIIb or greater were considered positive VUC results. Muscle-invasive or metastatic recurrences were considered progression. Risk factors for progression and cancer-specific mortality (CSM) were determined using time-fixed and time-dependent Cox models. Variables at the study entry and at each TURBT were used for time-fixed and time-dependent models, respectively. RESULTS The 5-year cumulative progression and CSM rates were, respectively, 7% and 5% (median follow-up, 46 months). The 5-year cumulative progression and CSM rates for patients with positive VUC were 20% and 15%, respectively, compared with 2% (P < .0001) and 2% (P = .0002), respectively, for patients with negative VUC results. A positive VUC result was a significant and independent risk factor for progression and CSM in the time-fixed and time-dependent models. In time-dependent models, 7 predictors for progression or CSM were identified (positive VUC results, T1 disease, lack of intravesical instillation, higher prior recurrence rate, higher histological grade, male gender, and advanced age), whereas 3 predictors were identified in time-fixed models (positive VUC, T1 disease, and higher prior recurrence rate). VUC results consistently outperformed histological grade as a prognostic predictor. CONCLUSION Positive VUC results predict the progression and CSM of NMIBC, independent of and outperforming histological grade.