Oncologic outcomes of neoadjuvant chemotherapy in patients with micropapillary variant urothelial carcinoma of the bladder.

BACKGROUND: There is lack of consensus about the effectiveness of neoadjuvant platinum-based chemotherapy in patients with micropapillary variant urothelial carcinoma (MVUC) prior to radical cystectomy. We studied the association between neoadjuvant chemotherapy (NAC) and pathologic response (PR) among patients with micropapillary versus non-variant bladder urothelial carcinoma (UC). METHODS: We queried the National Cancer Database to identify patients with localized UC and MVUC from 2004 to 2017. We restricted our analysis to patients who underwent radical cystectomy with or without NAC. We compared clinical, demographic, and pathologic characteristics associated with NAC. We used multivariable logistic regression and propensity score matching to examine the association between NAC and the occurrence of a pathologic complete response (pT0) and pathologic lymph node positivity (pN+). Kaplan Meier analyses and Cox proportional hazards models were used to assess overall survival (OS). We performed analyses among subsets of patients with clinical stage II (cT2) disease, as well as the entire cohort (cT2-T4). RESULTS: We identified 18,761 patients, including 18,027 with non-variant UC and 734 patients with MVUC. Multivariable analysis revealed that NAC use was associated with greater odds of pT0 (9.64[7.62-12.82], P<0.001), and the association did not differ significantly between MVUC and non-variant UC. In a propensity matched analysis of patients with MVUC, NAC use was associated with higher odds of pT0 (OR 4.93 [2.43-13.18] P<0.001), lower odds of pN+ (OR 0.52 [0.26-0.92] P=0.047) and pathologic upstaging (OR 0.63 [0.34-0.97] P=0.042) in all stages. Similar findings were observed with cT2 disease. No significant association was seen between NAC and OS with MVUC (HR 0.89 [0.46-1.10] P=0.63), including the subset of patients with cT2 (HR 0.83 [0.49-1.06] P=0.58). CONCLUSIONS: NAC is associated with similar pathologic and nodal responses in patients with localized MVUC and non-variant UC. Improvements in pathologic findings did not translate into OS in this retrospective hospital-based registry study.

Toradol to Reduce Ureteroscopy Symptoms Trial (TRUST).

OBJECTIVE: To assess the use of intraoperative IV ketorolac (Toradol) on the peri-operative total morphine milligram equivalent (MME) requirements of patients undergoing ureteroscopy for nephrolithiasis. METHODS: Patients undergoing ambulatory ureteroscopy for nephrolithiasis were randomized to receive ketorolac at time of anesthesia induction. Patients and surgeons were blinded to treatment. Intraoperative, postoperative and combined MME were calculated. Multivariable regression was used to identify independent predictors of MME requirement. Complications were recorded. RESULTS: A total of 94 patients were analyzed following randomization. There were 46 patients in the treatment arm and 48 patients in the control arm. There were no statistically significant differences in gender, age, BMI, operative length or baseline pain medication use between groups (P >.05). Patients in the treatment arm required lower intraoperative MME when compared to the control arm (17.1 vs 24, P< .01). There were no statistically significant differences in the postoperative MME requirements between groups. The combined peri-operative MME was lower in the treatment arm compared to the control arm (22.2 vs 30.4, P< .02). Ketorolac use was an independent predictor of lower MME use on multivariable analysis (beta coefficient -5.1, P< .01). There was no statistically significant difference with regards to complication numbers between the treatment arms. CONCLUSION: Ketorolac during ureteroscopy is associated with a 37% reduction in narcotic requirement and is an independent predictor of decreased peri-operative narcotic needs. These findings show that intra-operative use of ketorolac effectively reduces narcotic requirements and should be considered independently or as part of a multimodal pain control protocol, unless otherwise contraindicated.

Optimal Use of Tumor-Based Molecular Assays for Localized Prostate Cancer.

PURPOSEOF REVIEW: The use of genomic testing for prostate cancer continues to grow; however, utilization remains institutionally dependent. Herein, we review current tissue-based markers and comment on current use with active surveillance and prostate MRI. RECENT FINDINGS: While data continues to emerge, several studies have shown a role for genomic testing for treatment selection. Novel testing options include ConfirmMDx, ProMark, Prolaris, and Decipher, which have shown utility in select patients. The current body of literature on this specific topic remains very limited; prospective trials with long-term follow-up are needed to improve our understanding on how these genomic tests fit when combined with our current clinical tools. As the literature matures, it is likely that newer risk calculators that combine our classic clinical variables with genomic and imaging data will be developed to bring about standard protocols for prostate cancer decision-making.

Doubling of Decipher Biopsy Genomic Score Is Related to Disease Reclassification on Subsequent Surveillance Biopsy but Not Adverse Features on Radical Prostatectomy.

The utility of serial Decipher biopsy scores in a true active surveillance population is still unknown. In a man on active surveillance for low-risk prostate cancer, a doubling of the Decipher biopsy score within genomic low-risk category from first to the second biopsy related to biopsy reclassification to Gleason grade group 4 on the third biopsy. However, the final pathology at radical prostatectomy showed Gleason grade group 2 with an organ-confined disease. This case suggests that the genomic risk category of Decipher biopsy scores during active surveillance may be more informative than either the interval genomic score change or the biopsy Gleason grade group.

Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index.

INTRODUCTION: Feminizing gender-affirming surgery (GAS) has been an increasingly used procedure in the United States and worldwide for transgender women with gender dysphoria. Studies on patient-reported quality of life outcomes in those undergoing GAS remain limited. OBJECTIVE: To provide recent insights from the literature on sexual metrics in the evaluation of the transgender women. METHODS: We queried PubMed to identify studies assessing sexual function metrics in those undergoing feminizing GAS. RESULTS: There is no single validated method to establish preoperative and postoperative sexual function. Assessment currently remains institutionally dependent. Evaluation can involve questionnaires including but not limited to the International Index of Erectile Function, the Female Sexual Function Index, and the Male to Female Sexual Function Index. CONCLUSION: In this literature review, we discuss considerations for the evaluation of sexual function for patients considering feminizing GAS with vaginoplasty. Although we describe some of the major tools currently used in evaluating sexual function in this patient population, a need for a validated method remains. Syed JS, Honig S. Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index. Sex Med Rev 2021;9:236-243.

Distinguishing Benign Renal Tumors with an Oncocytic Gene Expression (ONEX) Classifier.

Renal oncocytoma (RO) accounts for 5% of renal cancers and generally behaves as a benign tumor with favorable long-term prognosis. It is difficult to confidently distinguish between benign RO and other renal malignancies, particularly chromophobe renal cell carcinoma (chRCC). Therefore, RO is often managed aggressively with surgery. We sought to identify molecular biomarkers to distinguish RO from chRCC and other malignant renal cancer mimics. In a 44-patient discovery cohort, we identified a significant differential abundance of nine genes in RO relative to chRCC. These genes were used to train a classifier to distinguish RO from chRCC in an independent 57-patient cohort. The trained classifier was then validated in five independent cohorts comprising 89 total patients. This nine-gene classifier trained on the basis of differential gene expression showed 93% sensitivity and 98% specificity for distinguishing RO from chRCC across the pooled validation cohorts, with a c-statistic of 0.978. This tool may be a useful adjunct to other diagnostic modalities to decrease the diagnostic and management uncertainty associated with small renal masses and to enable clinicians to recommend more confidently less aggressive management for some tumors. PATIENT SUMMARY: Renal oncocytoma is generally a benign form of kidney cancer that does not necessarily require surgical removal. However, it is difficult to distinguish renal oncocytoma from other more aggressive forms of kidney cancer, so it is treated most commonly with surgery. We built a classification tool based on the RNA levels of nine genes that may help avoid these surgeries by reliably distinguishing renal oncocytoma from other forms of kidney cancer.

Outcomes of Serial Multiparametric Magnetic Resonance Imaging and Subsequent Biopsy in Men with Low-risk Prostate Cancer Managed with Active Surveillance.

BACKGROUND: Outcomes of serial multiparametric magnetic resonance imaging (mpMRI) and subsequent biopsy in monitoring prostate cancer (PCa) in men on active surveillance (AS) have not been defined clearly. OBJECTIVE: To determine whether changes in serial mpMRI can predict pathological upgrade among men with grade group (GG) 1 PCa managed with AS. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of men with GG1 on AS with at least two consecutive mpMRI examinations during 2012-2018 who underwent mpMRI/ultrasound fusion or systematic biopsies. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Progression on serial mpMRI was evaluated as a predictor of pathological upgrading to GG≥2 on a follow-up biopsy using clinical, pathological, and imaging factors in binary logistic regression. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were determined. RESULTS AND LIMITATIONS: Of 122 patients, 29 men (23.8%) experienced pathological upgrade on the follow-up biopsy. Progression on mpMRI was not associated with pathological upgrade. The sensitivity, specificity, PPV, and NPV of mpMRI progression for predicting pathological upgrade were 41.3%, 54.8%, 22.2%, and 75%, respectively. Age (odds ratio [OR] 1.17, p=0.006), Prostate Imaging Reporting and Data System (PI-RADS) score on initial mpMRI (4-5 vs ≤3, OR 7.48, p=0.01), number of positive systematic cores (OR 1.84, p=0.03), number of positive targeted cores (OR 0.44, p=0.04), and maximum percent of targeted core tumor involvement (OR 1.04, p=0.01) were significantly associated with pathological upgrade. CONCLUSIONS: We did not observe an association between mpMRI progression and pathological upgrade; however, a PI-RADS score of 4-5 on initial mpMRI was predictive of subsequent pathological progression. The continued use of systematic and fusion biopsies appears necessary due to risks of reclassification over time. PATIENT SUMMARY: Progression on serial multiparametric magnetic resonance imaging during active surveillance (AS) is not associated with progression on the follow-up biopsy. Both systematic and fusion biopsies are necessary to sufficiently capture progression during AS.

Transcriptomics in RCC.

Improvements in chemistry, molecular biology, genetics, and bioinformatics have allowed broad use of transcriptomic profiling. Understanding the population of ribonucleic acid (RNA) transcripts can provide important clinical information relevant to kidney cancer care. This includes a better understanding of kidney cancer subtype and distinct clusters within these categories. RNA-sequencing (RNA-seq) is typically done on a region within the tumor, which represents thousands to millions of heterogeneous cells and various components of the microenvironment. Computational tools can deconvolute these populations to provide insight into the microenvironment. Specific signatures of hypoxia, proliferation, angiogenesis and immune infiltration can predict response and survival. Prognostic signatures can risk stratify tumors to aid in identification of patients who might derive benefit from adjuvant therapy. As the cost of sequencing continues to decline and improved bioinformatic tools are developed, the barriers to clinical use of transcriptomic data continue to crumble. Here we review the current literature around the use of transcriptomics in kidney cancer diagnosis and management.

Effect of Diaphragmatic Breathing on Procedural Anxiety During Transrectal Prostate Biopsy.

OBJECTIVE: To improve the tolerability of transrectal ultrasound guided prostate biopsy through use of diaphragmatic breathing. METHODS: Forty-seven patients, aged 52-79 years, who were scheduled for a transrectal ultrasound guided prostate biopsy with or without MRI guidance, were recruited at a single Veterans Affairs medical center for the diagnosis or evaluation of prostate cancer. Patients either met with a health psychologist for a 1-time, diaphragmatic breathing intervention immediately prior to their biopsy, or received usual care. All biopsies were performed using local anesthetic without sedation or anxiolytic therapy. The primary outcome was the difference in self-reported procedural situational anxiety as measured with the State Trait Anxiety Inventory, assessed both pre- and post-transrectal ultrasound guided prostate biopsy. We also examined secondary outcomes including physiological parameters (heart rate and blood pressure). RESULTS: There were no significant differences in preprocedural anxiety or physiological parameters between patients who received the intervention and those who received usual care. Patients who received the intervention had a significantly larger decrease in situational anxiety from pre- to postprocedure (M = 14.15, SD = 6.64) compared with those who received usual care (M = 3.45, SD = 9.97); t (38) = -4.0, P <.000; d = 1.26. Patients who received the intervention had a significantly larger decrease in heart rate (bpm) from pre- to postprocedure (M = 10.63, SD = 12.21) compared with those who received usual care (M = 0.07, SD = 9.25); t (31) = 2.75 P = 0.010; d = 0.97. CONCLUSION: A guided diaphragmatic breathing intervention reduced procedural anxiety during prostate biopsy and improved patient experience.

Outcomes for urologic oncology procedures: are there differences between academic and community hospitals?

OBJECTIVE: To compare the rate of hospital-based outcomes including costs, 30-day readmission, mortality, and length of stay in patients who underwent major urologic oncologic procedures in academic and community hospitals. METHODS: We retrospectively reviewed the Vizient Database (Irving, Texas) from September 2014 to December 2017. Vizient includes ~ 97% of academic hospitals (AH) and more than 60 community hospitals (CH). Patients aged ≥ 18 with urologic malignancies who underwent surgical treatment were included. Chi square and Student t tests were used to compare categorical and continuous variables, respectively. RESULTS: We identified a total of 37,628 cases. There were 33,290 (88%) procedures performed in AH and 4330 (12%) in CH. These included prostatectomy (18,540), radical nephrectomy (rNx) 8059, partial nephrectomy (pNx) (5287), radical cystectomy (4421), radical nephroureterectomy (rNu) (1006), and partial cystectomy (321). There were no significant differences in 30-day readmission rates or mortality for any procedure between academic and community hospitals (Table 1), p > 0.05 for all. Length of stay was significantly lower for radical cystectomy and prostatectomy in AH (p < 0.01 for both) and lower for rNx in CH (p = 0.03). The mean direct cost for index admission was significantly higher in AH for rNx, pNx, rNu, and prostatectomy. Case mix index was similar between the community and academic hospitals. CONCLUSION: Despite academic and community hospitals having similar case complexity, direct costs were lower in community hospitals without an associated increase in readmission rates or deaths. Length of stay was shorter for cystectomy in academic centers.

Brain Metastasis From Renal-Cell Carcinoma: An Institutional Study.

BACKGROUND: Brain metastases (BM) are frequently observed in advanced renal-cell carcinoma (RCC). Historically these individuals have been excluded from clinical trials, but recently, with better local control, many can receive aggressive therapy after treatment. We evaluate our single-institution experience over various treatment eras. PATIENTS AND METHODS: Patients undergoing evaluation for RCC BM from 2001 to 2018 were identified from our institutional database. Clinical notes, demographics, comorbidities, histology, central nervous system (CNS) treatments, systemic therapy, and outcomes were reviewed. Overall survival (OS) and CNS recurrence-free survival (RFS) were evaluated by the Kaplan-Meier method. Cumulative incidence was evaluated using a competing risk model. RESULTS: We identified 158 patients with RCC BM, of whom 94.4% had clear-cell RCC, and 90.6% had extracranial metastases at diagnosis. Of these patients, 94 (60%) developed RCC BM over time, while 46 (29.1%) had RCC BM at initial presentation. Clinical symptoms were noted in 81.9% of patients. The median OS after diagnosis of RCC BM was 8.4 months, with a 3-year OS of 28.2%. The median CNS RFS was 8.5 months overall; however, those with one and more than one lesion had median CNS RFS of 12.4 and 6 months, respectively (P < .001). CONCLUSION: The majority of RCC patients with BM are symptomatic and had prior metastatic disease that progressed to the brain. Those with a solitary RCC BM are less likely to develop CNS recurrence after local therapy and are ideal candidates for enrollment onto clinical trials.

Association Between Tumor Multifocality on Multi-parametric MRI and Detection of Clinically-Significant Prostate Cancer in Lesions with Prostate Imaging Reporting and Data System (PI-RADS) Score 4.

OBJECTIVE: To investigate whether presence of multifocality on multi-parametric magnetic resonance imaging would increase the likelihood of detecting clinically-significant prostate cancer in a PI-RADS 4 lesion. METHODS: We identified patients with at least 1 PI-RADS 4 lesion who underwent multi-parametric magnetic resonance imaging-ultrasound fusion prostate biopsy. Patients were grouped into 1 of 4 cohorts-cohort 1 (a PI-RADS 4 index lesion and an additional PI-RADS 2 or 3 lesion), cohort 2 (single lesion with PI-RADS 4), cohort 3 (2 or more PI-RADS 4 lesions), or cohort 4 (a PI-RADS 4 lesion and an index lesion with PI-RADS 5). We compared the rate of grade group (GG) ≥ 2 pathology on targeted biopsy of PI-RADS 4 lesions between cohorts and evaluated clinical and radiological factors associated with cancer detection. RESULTS: The overall rate of GG ≥ 2 pathology in the PI-RADS 4 lesions was 35.2%. The rate of GG ≥ 2 pathology in the cohorts 1, 2, 3, and 4 was 21.7%, 36.3%, 49.1%, and 42.7%, respectively (P< .001). On multivariable analysis, age (OR1.06, P < .001), clinical stage T2 (OR1.59, P= .03), prostate-specific antigen density (OR1.43, P < .001), peripheral zone lesion (OR1.62, P = .04), and study cohort (cohort 2 vs 1, OR1.93, P = .006; and cohort 3 vs 1, OR3.28, P < .001) were significantly associated with the risk of GG ≥ 2 in the PI-RADS 4 lesion. CONCLUSION: On targeted biopsy of the PI-RADS 4 lesions, the proportion of GG ≥ 2 pathology is approximately 35%. Rate of GG ≥ 2 detection in PI-RADS 4 lesions might differ based on their location, multifocality, and PI-RADS classifications of other lesions identified.

Role of Core Number and Location in Targeted Magnetic Resonance Imaging-Ultrasound Fusion Prostate Biopsy.

The optimal method of magnetic resonance imaging (MRI)-ultrasound (US) fusion biopsy to adequately sample regions of interest (ROIs) remains unknown. We sought to determine the number and location of cores needed to adequately detect clinically significant prostate cancer (PCa). We identified patients undergoing MRI-US fusion prostate biopsy at our institution for known history or clinical suspicion of PCa. Multiparametric MRI studies were reviewed using Likert and Prostate Imaging Reporting and Data System (PI-RADS) v2 schema. Multiple targeted cores were taken from each ROI followed by 12-core systematic biopsy. In a distinct cohort of patients, lesions were targeted using a predetermined five-core template. We estimated cancers detected through sampling of five or fewer cores, assessed by core number and core location. We identified 744 patients with 581 lesions with PCa. Seventy-seven percent (279/361) of Gleason (G) ≥3+4 tumors and 72% (137/189) of G >3+4 tumors were detected on two-core sampling. Relative to all targeted cores, a two-core approach missed 16% of clinically significant cancers at first biopsy, 27% in prior negative, and 32% in active surveillance patients. Detection of G ≥3+4 cancers did not differ by core location. Sampling of two cores of ROIs misses nearly one-quarter of clinically significant PCa detected on additional sampling. PATIENT SUMMARY: We aimed to understand how the number of cores obtained from a suspicious area during prostate magnetic resonance imaging-ultrasound fusion biopsy affects cancer detection. We found that sampling of five cores missed substantially fewer cancers compared to two cores.

Outcomes of upper tract urothelial cancer managed non-surgically.

INTRODUCTION: Approximately 7% of patients with localized upper tract urothelial cancer (UTUC) are treated without definitive therapy. Understanding outcomes and alternative therapy would aid in counseling older patients with comorbidities. MATERIALS AND METHODS: We utilized the National Cancer Database to identify patients with localized UTUC managed non-surgically between 2004 and 2013. Patient demographics, comorbidity, tumor grade, and chemotherapy and radiation utilization were recorded. Survival analyses were performed with the Kaplan-Meier method and a cox proportional hazard regression model. RESULTS: We identified 3157 (10.9%) patients with localized UTUC who did not receive definitive surgery. Median age was 79 years, 55% were males, 79% had government health insurance, and 68% had a Charlson-Deyo Score (CDS) of 0. Tumor grade was low (grade 1 or 2) in 632 (36.4%) and high (grade 3 or 4) in 1104 (63.6%). Median overall survival (OS) for the cohort was 2.2 years, significantly shorter for patients with greater comorbidities. Chemotherapy or radiation was performed in 294 (9.3%) and 197 (6.3%) patients respectively. There were no OS differences for individuals receiving chemotherapy. Of patients who received radiation therapy, the median OS was 1.4 versus 2.0 years, (p < 0.001) favoring no radiation. Those with high grade tumors had worse survival (1.9 versus 3.8 years (p < 0.001). Significant predictors of shorter OS included older age, male gender, higher CDS, and government insurance. CONCLUSIONS: In this population-based cohort, 10.9% of patients with localized UTUC were managed non-surgically. There was no OS advantage noted in cohorts receiving chemotherapy and radiation therapy. Median OS was significantly shorter for those with higher grade disease, increasing comorbidity profile, male gender, and those with government insurance status.

Determinants of Active Surveillance in Patients With Small Renal Masses.

OBJECTIVE: To evaluate trends in the utilization of active surveillance (AS) in a nationally representative cancer database. AS has been increasingly recognized as an effective strategy for patients with small renal masses but little is known about national usage patterns. METHODS: We identified patients with clinical T1a renal masses within the National Cancer Database in 2010 through 2014. Patients were classified according to initial management strategy received including AS, surgery, ablation, or other treatment. We characterized time trends in the use of AS vs definitive therapy and examined clinical and socio-demographic determinants of AS among patients with small renal masses using multivariable logistic regression models. RESULTS: We identified 59,189 patients who satisfied the inclusion criteria. Of the total cohort, 1733 (2.9%) individuals received initial management with AS, while 57,456 (97.1%) received definitive treatment. Surveillance rates remained below 5% in all years. On multivariate analysis, patient age (OR: 1.08, 95% CI 1.08-1.09), smaller tumor size of <2 cm vs ≥2 cm (OR: 2.43, 95% CI: 2.20-2.7, P < .0001), management at an academic center vs community center (OR: 2.05, 95% CI: 1.83-2.29), and African American vs Caucasian race (OR: 1.56, 95% CI:1.35-1.80) were independently associated with use of AS as initial management. CONCLUSION: In a representative national cohort of patients with small renal masses, we observed clinical and facility-level differences in the utilization of active surveillance in patients with T1a renal masses. Further investigation is warranted to better understand the forces underlying initial management decisions for patients with small renal masses.

National trends and economic impact of surgical treatment for benign kidney tumors.

OBJECTIVES: Kidney masses suspicious for malignancy are frequently detected by cross-sectional imaging; however, little is known about the burden of surgical treatment for tumors found to be benign following excision. MATERIAL AND METHODS: We queried the National Inpatient Sample to identify records of individuals who received surgical treatment for renal neoplasms between 2004 and 2014. We characterized temporal treatment trends, patient demographics, treatment related complications, and charges. RESULTS: We identified 7,099 (8.5%) and 76,892 (91.5%) patients who were treated for benign and malignant tumors, respectively. Benign masses accounted for 14.8% of partial and 5.5% of radical nephrectomies. The rates of surgery for benign tumors have remained steady (P = 0.058). The frequency of inpatient death was higher in those with malignant disease (0.63% vs. 0.18%, P < 0.0001). Median length of stay was longer for individuals with malignant renal tumors (4.86 vs. 4.12 days, P < 0.0001). The total discharge bill adjusting for inflation for benign or malignant renal surgery increased each year (R2 = 0.428, R2 = 0.719, P = 0.001, P = 0.0311, respectively). As of 2014, the estimated national inpatient cost of management for benign renal tumors was $153 million dollars ($55,573/individual). CONCLUSIONS: 8.5% of inpatient renal surgical admissions are performed for benign masses. There has been a trend toward decreased operative management for benign renal tumors over time. Surgical management remains a significant economic burden. Efforts to prospectively evaluate modalities for pretreatment identification should be further pursued.

Risk factors for metachronous bilateral renal cell carcinoma: A surveillance, epidemiology, and end results analysis.

BACKGROUND: Patients treated for renal cell carcinoma (RCC) may be diagnosed with a metachronous, contralateral tumor. We evaluated the risks of contralateral tumor development using the Surveillance, Epidemiology, and End Results database. METHODS: Among RCC patients, we identified those with a metachronous, contralateral RCC diagnosed ≥1 year after primary diagnosis. We performed a competing risks analysis to evaluate associations between clinicopathologic factors and metachronous, bilateral RCC. Cumulative incidence and standardized incidence ratios (SIRs) were calculated. RESULTS: There were 80,403 cases of RCC identified, with a median follow-up of 8.3 years; of these, 1063 (1.3%) developed metachronous, contralateral RCC (median of 6 years after diagnosis). The cumulative incidence at 10, 20, and 30 years of follow-up was 1.5%, 3.1%, and 4.7%, respectively. An increased risk was observed among men (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.20-1.55), blacks (HR, 2.00; 95% CI, 1.71-2.33), and those with papillary histology (HR, 1.72; 95% CI, 1.41-2.10). Risk of metachronous disease decreased with increasing age at primary diagnosis (HR per 1-year increase, 0.97; 95% CI, 0.96-0.97). The SIRs were highest among those diagnosed at a younger age and remained elevated even after extended follow-up (>10 years). CONCLUSIONS: Our findings suggest that the cumulative incidence of metachronous, contralateral RCC may be higher than previously reported. Younger age, black race, papillary histology, and male sex increase the risk of metachronous, contralateral RCC development. The high SIRs seen in all demographic groups may support a rationale for lifelong surveillance, especially in high-risk subgroups with early disease onset.

MRI-Ultrasound Fusion Targeted Biopsy of Prostate Imaging Reporting and Data System Version 2 Category 5 Lesions Found False-Positive at Multiparametric Prostate MRI.

OBJECTIVE: The purpose of this study was to determine imaging and clinical features associated with Prostate Imaging Reporting and Data System (PI-RADS) category 5 lesions identified prospectively at multiparametric MRI (mpMRI) that were found benign at MRI-ultrasound fusion targeted biopsy. MATERIALS AND METHODS: Between January 2015 and July 2016, 325 men underwent prostate mpMRI followed by MRI-ultrasound fusion targeted biopsy of 420 lesions prospectively identified and assessed with PI-RADS version 2. The frequency of clinically significant prostate cancer (defined as Gleason score ≥ 7) among PI-RADS 5 lesions was determined. Lesions with benign pathologic results were retrospectively reassessed by three abdominal radiologists and categorized as concordant or discordant between mpMRI and biopsy results. Multivariate logistic regression was used to identify factors associated with benign disease. Bonferroni correction was used. RESULTS: Of the 98 PI-RADS 5 lesions identified in 89 patients, 18% (18/98) were benign, 10% (10/98) were Gleason 6 disease, and 71% (70/98) were clinically significant prostate cancer. Factors associated with benign disease at multivariate analysis were lower prostate-specific antigen density (odds ratio [OR], 0.88; p < 0.001) and apex (OR, 3.54; p = 0.001) or base (OR, 7.11; p = 0.012) location. On secondary review of the 18 lesions with benign pathologic results, 39% (7/18) were scored as benign prostatic hyperplasia nodules, 28% (5/18) as inflammatory changes, 5% (1/18) as normal anatomic structures, and 28% (5/18) as discordant with imaging findings. CONCLUSION: PI-RADS 5 lesions identified during routine clinical interpretation are associated with a high risk of clinically significant prostate cancer. A benign pathologic result was significantly correlated with lower prostate-specific antigen density and apex or base location and most commonly attributed to a benign prostatic hyperplasia nodule. Integration of these clinical features may improve the interpretation of high-risk lesions identified with mpMRI.