Molecular imaging of prostate cancer: Review of imaging agents, modalities, and current status. / Técnicas de imagen molecular en el cáncer de próstata: revisión de radiofármacos, modalidades y evidencia actual.

INTRODUCTION: The clinical course of Prostate cancer (PCa) are markedly diverse, ranging from indolent to highly aggressive disseminated disease. Molecular imaging techniques are playing an increasing role in early PCa detection, staging and disease recurrence. There are some molecular imaging modalities, radiotracers agents and its performance are important in current clinical practice PCa. OBJECTIVE: This review summarizes the latest information regarding molecular imaging of PCa and is designed to assist urologists with ordering and interpreting these modalities and different radiotracers for different patients. EVIDENCE ACQUISITION: A PubMed-based literature search was conducted up to September 2019. We selected the most recent and relevant original articles, metanalysis and reviews that have provided relevant information to guide molecular imaging modalities and radiotracers use. EVIDENCE SYNTHESIS: In this review, we discuss 3 main molecular imaging modalities and 7 radiotracer technologies available. CONCLUSIONS: The use molecular imaging modalities and radiotracers has a unique role in biochemical recurrence and diagnosis of ganglionar and bone progression of PCa. In the present time, no one of these molecular imaging modalities can be recommended over the classical work-up of abdominopelvic CT scan and bone scan, and large-scale and multi-institutional studies are required to validate the efficacy and cost utility of these new technologies.

Multidisciplinary total eradication therapy (TET) in men with newly diagnosed oligometastatic prostate cancer.

To evaluate the outcomes of total eradication therapy (TET), designed to eradicate all sites of visible cancer and micrometastases, in men with newly diagnosed oligometastatic prostate cancer (OMPCa). Men with ≤ 5 sites of metastases were enrolled in a prospective registry study, underwent neoadjuvant chemohormonal therapy, followed by radical prostatectomy, adjuvant radiation (RT) to prostate bed/pelvis, stereotactic body radiation therapy (SBRT) to oligometastases, and adjuvant hormonal therapy (HT). When possible, the prostate-specific membrane antigen targeted 18F-DCFPyL PET/CT (18F-DCFPyL) scan was obtained, and abiraterone was added to neoadjuvant HT. Twelve men, median 55 years, ECOG 0, median PSA 14.7 ng/dL, clinical stages M0-1/12 (8%), M1a-3/12 (25%) and M1b-8/12 (67%), were treated. 18F-DCFPyL scan was utilized in 58% of cases. Therapies included prostatectomy 12/12 (100%), neoadjuvant [docetaxel 11/12 (92%), LHRH agonist 12/12 (100%), abiraterone + prednisone 6/12 (50%)], adjuvant radiation [RT 2/12 (17%), RT + SBRT 4/12 (33%), SBRT 6/12 (50%)], and LHRH agonist 12/12 (100%)]. 2/5 (40%) initial patients developed neutropenic fever (NF), while 0/6 (0%) subsequent patients given modified docetaxel dosing developed NF. Otherwise, TET resulted in no additive toxicities. Median follow-up was 48.8 months. Overall survival was 12/12 (100%). 1-, 2-, and 3-year undetectable PSA's were 12/12 (100%), 10/12 (83%) and 8/12 (67%), respectively. Median time to biochemical recurrence was not reached. The outcomes suggest TET in men with newly diagnosed OMPCa is safe, does not appear to cause additive toxicities, and may result in an extended interval of undetectable PSA.

Active surveillance is superior to radical nephrectomy and equivalent to partial nephrectomy for preserving renal function in patients with small renal masses: Results from the DISSRM registry.

PURPOSE: We compared renal function outcomes among patients in the surveillance and intervention arms of the DISSRM registry. MATERIALS AND METHODS: Patients were grouped into chronic kidney disease stages by estimated glomerular filtration rate range. Cases were considered up staged if a more advanced chronic kidney disease stage was entered during followup. Chronic kidney disease up staging-free survival was compared among groups using Kaplan-Meier analysis and paired comparisons log rank tests. Multivariate Cox regression identified independent predictors of chronic kidney disease up staging-free survival. RESULTS: A total of 162 patients met the study inclusion criteria, with 68 in the surveillance arm, 65 undergoing partial nephrectomy, 15 undergoing radical nephrectomy, and 14 undergoing cryoablation. Median tumor size was 2.2cm. Mean estimated glomerular filtration rate change was significantly larger for radical nephrectomy vs. surveillance (-9.2 vs. -0.5ml/min/1.73m2) and for radical vs. partial nephrectomy (-9.2 vs. -1.9ml/min/1.73m2) (P = 0.001). No other groups differed significantly. On Kaplan-Meier analysis, patients undergoing radical nephrectomy had significantly worse chronic kidney disease up staging-free survival vs. those treated with partial nephrectomy (P = 0.029), surveillance (P = 0.007), and cryoablation (P = 0.019). No other groups differed significantly. On multivariate analysis, radical nephrectomy independently predicted poor chronic kidney disease up staging-free survival (odds ratio vs. surveillance 30.6, P = 0.001). Neither partial nephrectomy (P = 0.985) nor cryoablation (P = 0.976) predicted poor chronic kidney disease up staging-free survival relative to surveillance. CONCLUSIONS: Patients in the surveillance arm had superior estimated glomerular filtration rate preservation compared to those in the radical nephrectomy but not the partial nephrectomy arm. In certain patients with small renal masses, surveillance and partial nephrectomy may offer comparable renal functional outcomes. This could be partly attributable to a modest estimated glomerular filtration rate decrease associated with surveillance itself. A thorough understanding of the renal functional impacts of treatment modalities is critical in the management of small renal masses.

PET imaging of prostate-specific membrane antigen in prostate cancer: current state of the art and future challenges.

BACKGROUND: Prostate-specific membrane antigen (PSMA) is a cell surface enzyme that is highly expressed in prostate cancer (PCa) and is currently being extensively explored as a promising target for molecular imaging in a variety of clinical contexts. Novel antibody and small-molecule PSMA radiotracers labeled with a variety of radionuclides for positron emission tomography (PET) imaging applications have been developed and explored in recent studies. METHODS: A great deal of progress has been made in defining the clinical utility of this class of PET agents through predominantly small and retrospective clinical studies. The most compelling data to date has been in the setting of biochemically recurrent PCa, where PSMA-targeted radiotracers have been found to be superior to conventional imaging and other molecular imaging agents for the detection of locally recurrent and metastatic PCa. RESULTS: Early data, however, suggest that initial lymph node staging before definitive therapy in high-risk primary PCa patients may be limited, although intraoperative guidance may still hold promise. Other examples of potential promising applications for PSMA PET imaging include non-invasive characterization of primary PCa, staging and treatment planning for PSMA-targeted radiotherapeutics, and guidance of focal therapy for oligometastatic disease. CONCLUSIONS: However, all of these indications and applications for PCa PSMA PET imaging are still lacking and require large, prospective, systematic clinical trials for validation. Such validation trials are needed and hopefully will be forthcoming as the fields of molecular imaging, urology, radiation oncology and medical oncology continue to define and refine the utility of PSMA-targeted PET imaging to improve the management of PCa patients.

Resection of isolated renal cell carcinoma metastases of the pancreas: outcomes from the Johns Hopkins Hospital.

PURPOSE: This study aims to assess outcomes and characteristics associated with resection of metastatic renal cell carcinoma (mRCC) to the pancreas. MATERIALS AND METHODS: From April 1989 to July 2012, a total of 42 patients underwent resection of pancreatic mRCC at our institution. We retrospectively reviewed records from a prospectively managed database and analyzed patient demographics, comorbidities, perioperative outcomes, and overall survival. Cox proportional hazards models were used to evaluate the association between patient-specific factors and overall survival. RESULTS: The mean time from resection of the primary tumor to reoperation for pancreatic mRCC was 11.2 years (range, 0-28.0 years). In total, 17 patients underwent pancreaticoduodenectomy, 16 underwent distal pancreatectomy, and 9 underwent total pancreatectomy. Perioperative complications occurred in 18 (42.9%) patients; there were two (4.8%) perioperative mortalities. After pancreatic resection, the median follow-up was 7.0 years (0.1-23.2 years), and median survival was 5.5 years (range, 0.4-21.9). The overall 5-year survival was 51.8%. On univariate analysis, vascular invasion (hazard ratio, 5.15; p = 0.005) was significantly associated with increased risk of death. CONCLUSIONS: Pancreatic resection of mRCC can be safely achieved in the majority of cases and is associated with long-term survival. Specific pathological factors may predict which patients will benefit most from resection.

Laparoscopic live donor nephrectomy with vaginal extraction: initial report.

The recent decrease in the total number of living kidney transplants coupled with the increase in the number of candidates on the waiting list underscores the importance of eliminating barriers to living kidney donation. We report what we believe to be the first pure right-sided laparoscopic live donor nephrectomy with extraction of the kidney through the vagina. The warm ischemia time was 3 min and the renal vessels and ureter of the procured kidney were of adequate length for routine transplantation. The donor did not receive any postoperative parenteral narcotic analgesia, was discharged home within 24 h and was back to normal activity in 14 days. The kidney functioned well with no complications or infections. Laparoscopic live donor nephrectomy with vaginal extraction may be a viable alternative to open and standard laparoscopic approaches. Potential advantages include reduced postoperative pain, shorter hospital stay and convalescence and a more desirable cosmetic result. These possible, but yet unproven, advantages may encourage more individuals to consider live donation.

Laparoscopic bowel injury: incidence and clinical presentation.

PURPOSE: Bowel injury is a potential complication of any abdominal or retroperitoneal surgical procedure. We determine the incidence and assess the sequelae of laparoscopic bowel injury, and identify signs and symptoms of an unrecognized injury. MATERIALS AND METHODS: Between July 1991 and June 1998 laparoscopic urological procedures were performed in 915 patients, of whom 8 had intraoperative bowel perforation or abrasion injuries. In addition, 2 cases of unrecognized bowel perforation referred from elsewhere were reviewed. A survey of the surgical and gynecological literature revealed 266 laparoscopic bowel perforation injuries in 205,969 laparoscopic cases. RESULTS: In our series laparoscopic bowel perforation occurred in 0.2% of cases (2) and bowel abrasion occurred in 0.6% (6). The 6 bowel abrasion injuries were recognized intraoperatively and 5 were repaired immediately. In 4 cases, including 2 referred from elsewhere, perforation injuries were not recognized intraoperatively and they had an unusual presentation postoperatively. These patients had severe, single trocar site pain, abdominal distention, diarrhea and leukopenia followed by acute cardiopulmonary collapse secondary to sepsis within 96 hours of surgery. The combined incidence of bowel complications in the literature was 1.3/1,000 cases. Most injuries (69%) were not recognized at surgery. Of the injuries 58% were of small bowel, 32% were of colon and 50% were caused by electrocautery. Of the patients 80% required laparotomy to repair the bowel injuries. CONCLUSIONS: Bowel injury following laparoscopic surgery is a rare complication that may have an unusual presentation and devastating sequelae. Any bowel injury, including serosal abrasions, should be treated at the time of recognition. Persistent focal pain in a trocar site with abdominal distention, diarrhea and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury.

Laparoscopic visual field. Voice vs foot pedal interfaces for control of the AESOP robot.

BACKGROUND: In order for robotic devices to be introduced successfully into surgical practice, the development of transparent surgeon/machine interfaces is critical. METHODS: This study evaluated the standard foot pedal for the AESOP robot compared to a voice control interface. Speed, accuracy, learning curves, durability of learning at 2 weeks, and operator-interface failures were analyzed in an ex vivo model. RESULTS: Foot control was faster and had less operator-interface failures. Voice control was more accurate as measured by "pass points." The foot control learning curve reached a plateau at the third trial, while the voice control did not fully plateau. Durability of learning favored the foot control but was not significantly different. CONCLUSIONS: Currently, the voice control is more accurate and has the advantage of not requiring the surgeon to look away from the operative field. However, it is slower and may require more attention as an interface. As voice recognition software continues to advance, speed and transparency are anticipated to improve.