The Added Value of Systematic Sampling in In-Bore Magnetic Resonance Imaging-Guided Prostate Biopsy.

We sought to quantify the additive value of systematic biopsy (SB) using in-bore magnetic resonance (MR)-guided prostate biopsy (IBMRGpB) by retrospectively reviewing the records of 189 patients who underwent IBMRGpB for suspected prostate cancer or as part of the surveillance protocol for previously diagnosed prostate cancer. The endpoints included clinically significant and non-clinically significant cancer diagnosis. SB detected clinically significant disease in 67 (35.5%) patients. Five (2.65%) patients whose targeted biopsies indicated benign or non-clinically significant disease had clinically significant disease based on SB. SB from the lobe contralateral to the lesion detected clinically significant disease in 15 (12%) patients. The size of the prostate was larger and the percentage of lesions located in the peripheral zone of the prostate was higher in patients with SB-detected clinically significant disease. The location of the main lesion in the peripheral zone of the prostate was a predictor for clinically significant disease in the multivariate analysis (OR = 8.26, p = 0.04), a finding supported by a subgroup analysis of biopsy-naïve patients (OR = 10.52, p = 0.034). The addition of SB during IBMRGpB increased the diagnosis of clinically significant as well as non-clinically significant prostate cancer. The location of the main lesion in the peripheral zone emerged as a positive predictive factor for clinically significant disease based on SB. These findings may enhance patient-tailored management.

Prostate lesions characterization using diffusion-weighted spatiotemporal encoded MRI: Feasibility and initial assessment.

PURPOSE: To assess the feasibility and reliability of a DWI protocol based on spatiotemporally encoding (SPEN), to target prostate lesions along guidelines normally used in EPI-based DWI clinical practice. METHODS: Prostate Imaging-Reporting and Data System recommendations underlying clinical prostate scans were used to develop a SPEN-based DWI protocol, which included a novel, local, low-rank regularization algorithm. These DWI acquisitions were run at 3 T under similar nominal spatial resolutions and diffusion-weighting b-values as used in EPI-based clinical studies. Prostates of 11 patients suspected of clinically significant prostate cancer lesions were therefore scanned using the two methods, with the same number of slices, same slice thickness, and same interslice gaps. RESULTS: Of the 11 patients scanned, SPEN and EPI provided comparable information in 7 of the cases, whereas EPI was deemed superior in a case for which SPEN images had to be acquired with a shorter effective TR owing to scan-time constraints. SPEN provided reduced susceptibility to field-derived distortions in 3 of the cases. CONCLUSIONS: SPEN's ability to provide prostate lesion contrast was most clearly evidenced for DW images acquired with b ≥ 900 s/mm2 . SPEN also succeeded in decreasing occasional image distortions in regions close to the rectum, affected by field inhomogeneities. EPI advantages arose when using short effective TRs, a regime in which SPEN-based DWI was handicapped by its use of nonselective spin inversions, leading to the onset of an additional T1 weighting.

Response to Anti-PD1/L1 Antibodies in Advanced Urothelial Cancer in the 'Real-Life' Setting.

Immune checkpoint inhibitors (ICIs) are now the standard of care for metastatic urothelial carcinoma (mUC) patients. Our aim was to describe the activity of ICIs in mUC and find the clinical parameters associated with response. This is a retrospective, single-center chart review of mUC patients receiving ICIs. The overall survival (OS) was plotted using the Kaplan-Meier method and was compared using a log-rank test. Associations between the variables and responses were analyzed by univariate and multivariable analyses, using either logistic regression or a Chi-square/Fisher's exact test. Ninety-four patients received ICIs, 85% of which were in the second line or beyond; the median age was 71.8 years, and 82% were men. Six (6.4%), 11 (11.7%), 7 (7.4%) and 70 (74.5%) patients achieved a complete response (CR), partial response (PR), mixed response/stable disease (M/SD) or progressive disease (PD), respectively. The median overall survival was 3.2 months for the entire cohort and was significantly different according to the response pattern-not reached, 32.3, 6.4 and 2.0 months for CR, PR, M/SD and PD, respectively. The response was not significantly associated with the line of treatment. 'Site of metastasis' was associated with the response, and the absolute neutrophil count was borderline associated with the response. In summary, we found a substantial variance in the potential benefit from ICIs in mUC, emphasizing the need for predictive biomarkers and frequent monitoring of mUC patients receiving ICIs.

The urologist's learning curve of "in-bore" magnetic resonance-guided prostate biopsy.

BACKGROUND: The combination of multi-parametric MRI to locate and define suspected lesions together with their being targeted by an MRI-guided prostate biopsy has succeeded in increasing the detection rate of clinically significant disease and lowering the detection rate of non-significant prostate cancer. In this work we investigate the urologist's learning curve of in-bore MRI-guided prostate biopsy which is considered to be a superior biopsy technique. MATERIALS AND METHODS: Following Helsinki approval by The Chaim Sheba Medical Center ethics committee in accordance with The Sheba Medical Center institutional guidelines (5366-28-SMC) we retrospectively reviewed 110 IB-MRGpBs performed from 6/2016 to 1/2019 in a single tertiary center. All patients had a prostate multi-parametric MRI finding of at least 1 target lesion (prostate imaging reporting and data system [PI-RADS] score ≥ 3). We analyzed biopsy duration and clinically significant prostate cancer detection of targeted sampling in 2 groups of 55 patients each, once by a urologist highly trained in IB-MRGpBs and again by a urologist untrained in IB-MRGpBs. These two parameters were compared according to operating urologist and chronologic order. RESULTS: The patients' median age was 68 years (interquartile range 62-72). The mean prostate-specific antigen level and prostate size were 8.6 ± 9.1 ng/d and 53 ± 27 cc, respectively. The mean number of target lesions was 1.47 ± 0.6. Baseline parameters did not differ significantly between the 2 urologists' cohorts. Overall detection rates of clinically significant prostate cancer were 19%, 55%, and 69% for PI-RADS 3, 4 and 5, respectively. Clinically significant cancer detection rates did not differ significantly along the timeline or between the 2 urologists. The average duration of IB-MRGpB targeted sampling was 28 ± 15.8 min, correlating with the number of target lesions (p < 0.0001), and independent of the urologist's expertise. Eighteen cases defined the cutoff for the procedure duration learning curve (p < 0.05). CONCLUSIONS: Our data suggest a very short learning curve for IB-MRGpB-targeted sampling duration, and that clinically significant cancer detection rates are not influenced by the learning curve of this technique.

Salvage re-irradiation using stereotactic body radiation therapy for locally recurrent prostate cancer: the impact of castration sensitivity on treatment outcomes.

BACKGROUND: Advances in imaging, biomaterials and precision radiotherapy provide new opportunities to salvage locally recurrent prostate cancer (PC). This study evaluates the efficacy and safety of re-irradiation using stereotactic body radiation therapy (SBRT). We hypothesized that patients with castrate-resistant PC (CRPC) would benefit less from local salvage. METHODS: A prospective clinical database was reviewed to extract 30 consecutive patients treated with prostate re-irradiation. Gallium prostate specific membrane antigen (PSMA) ligand positron emission tomography was performed following prostate-specific antigen failure in all patients and biopsy was obtained in 18 patients (60%). Re-irradiation was either focal (n = 13) or whole-gland (n = 17). Endo-rectal balloons were used in twenty-two patients and hydrogel spacers in eight patients. The median prescription dose was 5 fractions of 6.5 (range: 6-8) Gray (Gy). RESULTS: Median follow-up was 28 months. Failure occurred in 10 (out of 11) CRPC patients versus 6 (out of 19) castrate-sensitive patients (91% vs. 32%, p = 0.008) after a median of 13 and 23 months, respectively. Metastases occurred in 64% (n = 7) of CRPC patients versus 16% (n = 3) of castrate-sensitive patients (p = 0.007). Two patients experienced local in-field recurrence, thus local control was 93%. The 2 and 3-year recurrence-free survival were 84% and 79% for castrate-sensitive patients versus 18% and 9% for CRPC patients (p < 0.001), and 3-year metastasis-free survival was 90% versus 27% (p < 0.01) for castrate-sensitive and CRPC patients, respectively. Acute grade II and III genitourinary (GU) toxicity occurred in 27% and 3%, and late GU toxicity in 30% and 3%, respectively. No ≥ grade II acute gastrointestinal (GI) toxicity occurred, and only one patient (3%) developed late grade II toxicity. CONCLUSIONS: Early delivery of salvage SBRT for local recurrence is associated with excellent 3-year disease control and acceptable toxicity in the castrate-sensitive phenotype. PSMA imaging for detection of local recurrence and the use of precision radiotherapy with rectal protective devices should be further investigated as a novel salvage strategy for radio-recurrent PC.

Oncologic Outcomes Following Robot-Assisted Radical Prostatectomy for Clinical T3 Prostate Disease.

BACKGROUND: Little is known about oncologic outcomes following robot-assisted-radical-prostatectomy (RALP) for clinical T3 (cT3) prostate cancer. OBJECTIVES: To investigate oncologic outcomes of patients with cT3 prostate cancer treated by RALP. METHODS: Medical records of patients who underwent RALP from 2010 to 2018 were retrieved. cT3 cases were reviewed. Demographic and pre/postoperative pathology data were analyzed. Patients were followed in 3-6 month intervals with repeat PSA analyses. Adjuvant/salvage treatments were monitored. Biochemical recurrence (BCR) meant PSA levels of ≥ 0.2 ng/ml. RESULTS: Seventy-nine patients met inclusion criteria. Median age at surgery was 64 years. Preoperative PSA level was 7.14 ng/dl, median prostate weight was 54 grams, and 23 cases (29.1%) were down-staged to pathological stage T2. Positive surgical margin rate was 42%. Five patients were lost to follow-up. Median follow-up time for the remaining 74 patients was 24 months. Postoperative relapse in PSA levels occurred in 31 patients (42%), and BCR in 28 (38%). Median time to BCR was 9 months. The overall 5-year BCR-free survival rate was 61%. Predicting factors for BCR were age (hazard-ratio [HR] 0.85, 95% confidence interval [95%CI] 0.74-0.97, P = 0.017) and prostate weight (HR 1.04, 95%CI 1.01-1.08, P = 0.021). Twenty-six patients (35%) received adjuvant/salvage treatments. Three patients died from metastatic prostate cancer 31, 52, and 78 months post-surgery. Another patient died 6 months post-surgery of unknown reasons. The 5-year cancer-specific survival rate was 92. CONCLUSIONS: RALP is an oncologic effective procedure for cT3 prostate cancer. Adjuvant/salvage treatment is needed to achieve optimal disease-control.

Very low-dose computerized tomography for confirmation of urinary stone presence.

PURPOSE: To determine whether a modified non-contrast very low-dose computed tomography (VLD-CT) protocol is applicable for confirmation of known urolithiasis. METHODS AND MATERIALS: Consecutive adult patients with a CT scan showing urinary tract stone(s) between 6/2017-12/2018 were included. They were referred to a modified VLD-CT protocol if stone presence was equivocal or if stone location needed reassessment before an endourological interventional procedure. The scanned area was limited to the level of initial stone location caudally. Data on patients' demographics andbody mass index, were collected. The scanned length and radiation dose were calculated. Images were reviewed by two radiologists who assessed stone size and location. Follow-up reference standard included stone passage, surgical removal, and other imaging and clinical information. RESULTS: Sixty-three patients [63 stones, mean BMI 28.7 (range 19-41.9)] were included. VLD-CTs revealed 31 stones in 31 patients, with a mean stone length of 5.5 mm. Fifteen stones remained at the same location, and 16 had migrated, of which two appeared in the bladder. Thirty-two stones were not observed on VLD-CT. The mean span scanned on the VLD-CT was 274 mm (± 80). The average radiation exposure was 1.47 mGy (range 1.09-3.3), and the absorbed dose was 0.77 mSv (range 0.39-1.43), compared to 10.24 mGy (range 1.75-28.9) and 7.87 mSv (range 1.44-18.5) in the previous scan. The mean radiation dose reduction between scans was 89%. On follow-up, all VLD-CT findings were confirmed. CONCLUSION: A modified imaging protocol is applicable for confirmation of stone presence and location by utilizing very low-dose radiation exposure.

Histology results of systematic prostate biopsies by in-bore magnetic resonance imaging vs. transrectal ultrasound.

INTRODUCTION: We aimed to compare systematic biopsies (SBs) of in-bore magnetic resonance-guided prostate biopsy (MRGpB) with those performed under transrectal ultrasound (TRUS) guidance in the clinical setting. METHODS: Data on all 161 consecutive patients undergoing prostate biopsy at our institution between November 2017 and July 2019 were retrospectively collected. The patients were referred to biopsy due to elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE) and/or at least one Prostate Imaging Reporting and Data System (PI-RADS) lesion score of ≥3 on multiparametric magnetic resonance imaging (mpMRI). We included patients with PSA levels ≤20 ng/ml and those with 8-12 core biopsies. Histology results of SBs performed by in-bore MRGpB were compared to TRUS SBs. Chi-squared, Fischer's exact, and multivariate Pearson regression tests were used for statistical analysis (SPSS, IBM Corporation). RESULTS: In total, 128 patients were eligible for analysis. Their median age was 68 years (interquartile range [IQR] 61.5-72), mean prostate size 55±29 cc, and mean PSA and PSA density levels 7.6±3.5 ng/ml and 0.18±0.13 ng/ml/cc, respectively. Thirty-five patients (27.3%) had suspicious DRE findings. Both biopsy groups were similar for these parameters. Thirty-eight (62.3%) MRGpB patients had a previous biopsy vs. five (7.1%) TRUS-SB patients (p<0.0001). The number of patients diagnosed with clinically significant and non-significant disease was similar for both groups. High-risk disease was more prevalent in the TRUS-SB group (22.4% vs. 4.9%, p<0.01). CONCLUSIONS: Our data suggest that in-bore MRGpB is no better than TRUS for guiding SBs for the detection of clinically significant prostate cancer.

Endoscopic Treatment for Large Multifocal Upper Tract Urothelial Carcinoma.

PURPOSE: We reviewed the oncologic and surgical outcomes of endoscopic treatments for low grade upper tract urothelial carcinoma, and assessed the prognostic significance of tumor size, location and multifocality. MATERIALS AND METHODS: We retrospectively reviewed all patients who underwent endoscopic treatment for low grade upper tract urothelial carcinoma at our institution between 2014 and 2019. Tumors were treated with a dual laser generator, which alternately produces holmium and neodymium lasers. A stringent ureteroscopic followup protocol was conducted. We looked for an association between outcome and tumor size, location or multifocality, and for predictive factors for time to local recurrence and progression. RESULTS: The cohort included 59 patients (62 renal units), 27% of tumors were multifocal and 40% were >2 cm. The median followup time was 22 months (IQR 11-41), and the median number of ureteroscopies was 5.5 (4-9). Local recurrence was observed in 46 renal units (74.1%) at a median of 6.5 months after initial surgery. Four patients (6.4%) developed disease progression and were referred for radical surgery: 2 had pathological progression and 2 had a rapid and high volume local recurrence, and 1 later developed metastatic disease. The progression-free rate was 93.2%. Tumor location in kidney (p=0.03, HR 1.95) and multifocality (p=0.005, HR 3.25) significantly predicted time to local recurrence. No factor predicted time to progression. CONCLUSIONS: Ureteroscopic treatment of large, multifocal, low grade upper tract urothelial carcinoma is feasible, does not involve significant complications and has good short-term oncologic outcomes, with a 93.2% progression-free survival rate. Tumors located in the kidney and multifocality yielded shorter time to local recurrence but not progression.

Powerful Chemiluminescence Probe for Rapid Detection of Prostate Specific Antigen Proteolytic Activity: Forensic Identification of Human Semen.

The prostate specific antigen (PSA), a serine protease with chymotrypsin-like activity, is predominantly expressed in the prostate and is considered as the most common marker in use to identify and follow the progress of prostate cancer. In addition, it is also now accepted as a marker for detecting semen in criminal cases. Here, we describe the design, synthesis, and evaluation of the first chemiluminescence probe for detection of PSA enzymatic activity. The probe activation mechanism is based on a catalytic cleavage of a specific peptidyl substrate, followed by a release of a phenoxy-dioxetane luminophore, that then undergoes efficient chemiexcitation to emit a green photon. The probe exhibits a significant turn-on response upon reaction with PSA and produces strong light emission signal with an extremely high signal-to-noise ratio. Comparison of the chemiluminescence probe with an analogous fluorescence probe showed superior detection capability in terms of response time and sensitivity. In addition, the probe was able to efficiently detect and image human semen traces on fabric, even after 3 days from sample preparation. The advantageous sensitivity and simplicity of a chemiluminescence assay to detect seminal fluid was effectively demonstrated by on-site measurements using a small portable luminometer. It is expected that the new chemiluminescence probe would be broadly useful for numerous applications in which PSA detection or imaging is required.

Effects of "real life" prostate MRI inter-observer variability on total needle samples and indication for biopsy.

PURPOSE: Prostate multiparametric magnetic resonance imaging (mpMRI) improves diagnosis of clinically significant cancer and reduces over-detection of nonsignificant cancer. Disagreement in the interpretation of mpMRI readings is well-known, with a reported discrepancy rate of 10% to 42%. We report the clinical repercussions of this variability on prostate biopsy candidates. MATERIALS AND METHODS: Medical records of patients referred from 11 medical centers for MR-guided prostate biopsy (MRGpB) between October, 2017 and January, 2019 were retrospectively analyzed. Patients with at least one prostate imaging reporting and data system (PI-RADS) 3 or greater prostate lesion were selected, and the mpMRI studies (all read by others) were reviewed by our prostate mpMRI reader. Outcomes included changes in PI-RADS score and the subsequent effect on total needle samples and indication for biopsy. RESULTS: Eighty-two patients with 128 lesions were suitable for analysis (mean age 66.5 ± 7.1 years, mean PSA 6.8 ± 8.5 ng/ml). Nine (11%) patients had suspicious rectal exams (T2a). Following our prostate mpMRI reader's imaging revisions, the PI-RADS score was downgraded in 66 (52%) lesions, upgraded in 15 (12%), and unchanged in 47 (37%), leaving a total of 84 suspected lesions (kappa = 0.17). Biopsy was deferred in 22 (27%) patients, and an estimated 136.4 (34.4%) samples were avoided (P = 0.0001 for both). There was a trend toward prostate size to correlate with imaging revision and abortion of biopsy (P = 0.06) while enrollment in active surveillance correlated with proof from such outcome (P = 0.007). CONCLUSION: These data suggest that high interobserver disagreement in prostate mpMRIs from diverse institutes significantly affects prostate biopsy practice. The clinical consequences of this discord are significant.

Selective Arterial Embolization for Large or Symptomatic Renal Angiomyolipoma: 10 Years of Follow-up.

OBJECTIVE: To assess long-term outcome after selective arterial embolization (SAE) as first-line treatment for large or symptomatic AML. DESIGN, SETTING, AND PARTICIPANTS: Data from a prospectively maintained database on 71 patients who underwent SAE for large or symptomatic AML were reviewed. Patients with sporadic and tuberous-sclerosis-complex (TSC) were included. OUTCOME MEASUREMENTS: The main endpoints were re-embolization rates, occurrence of clinical events related to AML, size of AML, and renal function. RESULTS: Thirteen (19.1%) patients reported at least 1 major clinical event. Major complications affected 2 patients (2.9%), both ending in complete loss of renal unit function. Four renal units (5.9%) were eventually treated surgically. The re-embolization rate was 41.1%, with an average time from the initial to a repeat SAE of 2.18 years (range 0.31-10.65 years). The size of the tumor prior to SAE and after 5 and 10 years of follow-up were 8.9 cm (7-12), 6.5 cm (4-7.5), 7 cm (4-7.8), respectively [median (IQR)]. These results are translated to a size reduction of 27% in 10 years follow-up. Patients with TSC had larger tumors on long-term follow-up (77.8 vs 41.3 mm, P = .045). The long-term follow-up estimated average glomerular filtration rate was 81.97 (range 26-196). No patient needed renal replacement therapy, and disease-specific survival was 100%. CONCLUSIONS: SAE is a safe treatment option for patients with symptomatic or large AML. It represents a minimally invasive intervention with good long-term outcome. SAE may be offered as first-line treatment in most cases, though, it is associated with high retreatment rates.

Gallium-68 prostate-specific membrane antigen PET-CT and the clinical management of prostate cancer.

OBJECTIVES: The purpose of this study was to evaluate the use of Gallium-68 prostatic-specific membrane antigen (PSMA) PET-computerized tomography (CT) in patients with prostate cancer undergoing imaging for initial staging, biochemical failure or the evaluation of metastatic disease. METHODS: This is a single institution retrospective study of 95 patients with prostate cancer who were referred for PSMA PET-CT scans. The National Comprehensive Cancer Network guidelines were used to generate treatment recommendations. Univariate and multivariate statistical analyses were performed to identify parameters associated with positive findings on a PET-CT PSMA scan. RESULTS: Mean age, Gleason score, and median prostate serum antigen (PSA) were: 72 years, 7.6 and 4 ng/ml, respectively. PSMA PET-CT was positive in 75.5% of the patients. A maximum standardized uptake value was 10.7 ± 8.8. PSMA avidity increased with rising PSA level: PSA ≤ 1 ng/ml: 5/15 patients (33%); PSA 1-5 ng/ml: 18/27 patients (67%), and PSA ≥ 5 ng/ml: 33/34 patients (97%). Following imaging in nine high-risk patients referred for staging, changes in treatment occurred in 6 (67%). Treatment recommendations changed in 27/35 (65%) patients referred due to biochemical failure; these included recurrences suitable for salvage therapy (n = 14), metastatic disease not suitable for salvage therapy (n = 10), and no lesion (n = 17). No changes in treatment occurred in any of the 35 patients referred to evaluate metastatic disease. DISCUSSION: PSMA PET-CT imaging may have a substantial impact on clinical management in prostate cancer patients at the time of initial staging or with biochemical failure; yet this modality does not appear useful in the management of patients with known metastatic disease.

The Diffusion Tensor Imaging Properties of the Normal Testicles at 3 Tesla Magnetic Resonance Imaging.

RATIONALE AND OBJECTIVES: The testicles are structured in a well-defined microtubular network formation, which is expected to be reflected in high anisotropic diffusivity. However, preliminary studies reported on low values of fractional-anisotropy (FA) in the normal testicles. Our aim was to design and apply a diffusion-tensor imaging (DTI) protocol in order to elucidate the diffusivity properties of the testicles and their determining factors. MATERIALS AND METHODS: 16 healthy volunteers were prospectively scanned at 3T. The protocol included T2-weighted and DTI sequences, the latter using 24 directional diffusion gradients and 3 b-values (0, 100, and 700 s/mm2) that were separated for analysis based on the reference b-value of 0 or 100 s/mm2. Image processing of the two DTI datasets yielded the diffusion vector maps and parametric maps of their corresponding principal diffusion coefficients λ1, λ2, λ3, mean diffusivity and FA. RESULTS: The results demonstrated the feasibility of DTI to provide parametric maps of the testicles. The diffusion tensor parameters obtained using the pair of 0 and 700 s/mm2 b-values, exhibited relatively low diffusivity, with mean λ1 values of 1.36 ± 0.21 × 10-3 mm2/s and low anisotropy, with mean FA values of 0.13 ± 0.05. Analysis of DTI using the 100 and 700 s/mm2 b-values yielded a slight decrease in the diffusivity of 4%-5%, whereas FA remained similar. CONCLUSION: The diffusivity of the normal testicles is relatively slow, closed-to isotropic and hardly affected by the low b-values regime exclusion. Thus, DTI parameters of the normal testicles are neither dictated by the underlying architectural anisotropy nor microperfusion effects.

Fully automatic detection of renal cysts in abdominal CT scans.

PURPOSE: Simple renal cysts are a common benign finding in abdominal CT scans. However, since they may evolve in time, simple cysts need to be reported. With an ever-growing number of slices per CT scan, cysts are easily overlooked by the overloaded radiologist. In this paper, we address the detection of simple renal cysts as an incidental finding in a real clinical setting. METHODS: We propose a fully automatic framework for renal cyst detection, supported by a robust segmentation of the kidneys performed by a fully convolutional neural network. A combined 3D distance map of the kidneys and surrounding fluids provides initial candidates for cysts. Eventually, a second convolutional neural network classifies the candidates as cysts or non-cyst objects. RESULTS: Performance was evaluated on 52 abdominal CT scans selected at random in a real radiological workflow and containing over 70 cysts annotated by an experienced radiologist. Setting the minimal cyst diameter to 10 mm, the algorithm detected 59/70 cysts (true-positive rate = 84.3%) while producing an average of 1.6 false-positive per case. CONCLUSIONS: The obtained results suggest the proposed framework is a promising approach for the automatic detection of renal cysts as incidental findings of abdominal CT scans.

Oncologic Outcomes of Partial Nephrectomy for Stage T3a Renal Cell Cancer.

BACKGROUND: Partial nephrectomy (PN) for clinical stage T3 tumors is controversial. Radical nephrectomy (RN) has been associated with a greater rate of chronic kidney disease, an increased risk of cardiovascular disease, and increased mortality compared with PN. We present our long-term 2-center experience with PN for stage pT3a tumors and compare the oncologic outcomes with those of similar patients treated with RN. MATERIALS AND METHODS: We reviewed the data from all patients who had undergone nephrectomy for renal cell carcinoma from 1987 to 2015 in 2 medical centers. The study included 134 patients with pathologic stage T3a tumors, of whom 48 and 86 underwent PN and RN, respectively. We compared the 2 groups (PN and RN) using univariate and multivariate analyses. RESULTS: The tumors of all patients with pathologic stage T3a who had undergone PN had been pathologically upstaged from clinical stage T1 or T2. Univariate and multivariate analyses revealed tumor size was significantly different statistically between the study groups (median, 7.0 cm in RN group vs. 4.0 cm in PN group; P < .001). Surgery type was not a predictor of local recurrence (P = .978), metastatic progression (P = .972), death from renal cancer (P = .626), or death from all causes (P = .974) at the 5-year follow-up point. CONCLUSION: The results of the present study have shown similar oncologic outcomes between 48 patients with stage pT3a renal cancer who underwent PN and 86 patients who underwent RN. Although PN was not performed on clinical T3a tumors, our findings suggest that PN can also be considered for these tumors and, thus, avoid the long-term complications of RN. However, strict follow-up protocols are mandatory.

CT measurement of breast glandular tissue and its association with testicular cancer.

OBJECTIVES: To evaluate the associations between breast glandular tissues diameters as determined by CT and b-hCG levels, histological types, tumour spread and prognosis in patients with testicular germ cell tumour. METHODS: Ninety-four patients with pre-treatment CT scan and markers (b-hCG, AFP, LDH) were retrospectively collected. A radiologist measured diameters in all CT examinations and correlation between diameters and log (b-hCG) was assessed (Pearson's coefficient). The ability of measured diameters to predict lymphatic and distant haematogenous metastatic spread was evaluated (ROC curves). The associations between measured diameter cut-off values of 20 and 25 mm and International Germ Cell Cancer Collaborative Group (IGCCCG) classification, lymphatic and distant haematogenous metastatic spread and histological subtypes were evaluated (chi squared test). RESULTS: Breast glandular diameters correlated to log(b-hCG) (r = 0.579) and predicted distant haematogenous metastatic spread (AUC = 0.78). Worse prognosis (intermediate or poor IGCCCG) was shown for 20 mm (27.3 vs. 4.2 %, p = 0.005) and 25 mm (33.3 vs. 6.1 %, p = 0.014). A diameter of 25 mm was associated with non-seminoma (91.7 vs. 48.8 %, p = 0.005). CONCLUSION: Breast glandular tissue diameters correlated with log(b-hCG) and predicted distant haematogenous metastases. Twenty and 25 mm were associated with worse prognosis and 25 mm was able to distinguish between seminoma and non-seminoma. KEY POINTS: • CT breast glandular tissue diameter correlates with log(b-HCG) • Gynaecomastia in CT is associated with worse prognosis • Gynaecomastia in CT is associated with non-seminoma histological subtype.

Can Unenhanced CT Findings Predict Interventional Versus Conservative Treatment in Acute Renal Colic?

OBJECTIVE: The purpose of this study was to determine the value of clinical parameters and radiologic findings on unenhanced CT to the choice between interventional and conservative management for patients with acute renal colic. MATERIALS AND METHODS: Unenhanced CT records of 183 consecutive patients with acute renal colic were retrospectively reviewed. Urolithiasis was confirmed at both unenhanced CT and clinical follow-up findings of 80 patients (study group). Clinical parameters (signs of infection and renal indexes) and unenhanced CT findings (tissue rim sign, hydronephrosis, perinephric and periureteral edema, ureteral dilatation, renal attenuation, and stone characteristics) were graded and correlated with the choice of clinical management. ROC analysis was constructed for the most statistically significant parameters. RESULTS: Forty-two patients (52%) were treated conservatively and 38 (48%) underwent interventional treatments. The relationship between shivering, fever, and leukocytosis and interventional treatment had low sensitivity (29%, 26%, and 16%, respectively) but very high specificity (98%, 95%, and 98%, respectively) (p < 0.05). Stone size and density were statistically significantly different between patients treated conservatively and those treated interventionally (size, 4.6 vs 6.7 mm; density, 730 vs 910 HU; p < 0.01). Stones larger than 6.5 mm with an attenuation value greater than 1100 HU and that were proximally located were more likely to be treated interventionally. CONCLUSION: Larger stone size, higher density, proximal location, and complaints of shivering, fever, and leukocytosis are the most important parameters for predicting invasive management of acute renal colic. Other clinical and radiologic information may be useful as supportive findings but do not predict the choice of patient management.

Marked Improvement in Refractory TTP Directly after H. pylori Eradication Therapy.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder involving thrombotic microangiopathy and is characterized by increased platelet aggregation throughout the body. Acquired TTP can be triggered by a variety of conditions including infections. We hereby describe a case report of an 81-year-old female presenting to the internal medicine department with TTP and active chronic gastritis, positive for Helicobacter pylori (H. pylori) on biopsy. The TTP was highly resistant to medical therapy; however the patient underwent complete resolution of her TTP following H. pylori eradication. We conclude that acquired TTP may be triggered by H. pylori infection and that treating the underlying infection may play a role in improving TTP's outcome in some patients, especially when disease is refractory to medical therapy.

Deformable registration of trans-rectal ultrasound (TRUS) and magnetic resonance imaging (MRI) for focal prostate brachytherapy.

PURPOSE: Focal therapy in low-risk prostate cancer may provide the best balance between cancer control and quality of life preservation. As a minimally invasive approach performed under TRUS guidance, brachytherapy is an appealing framework for focal therapy. However, the contrast in TRUS images is generally insufficient to distinguish the target lesion from normal prostate tissue. MRI usually offers a much better contrast between the lesion and surrounding tissues. Registration between TRUS and MRI may therefore significantly improve lesion targeting capability in focal prostate brachytherapy. In this paper, we present a deformable registration framework for the accurate fusion of TRUS and MRI prostate volumes under large deformations arising from dissimilarities in diameter, shape and orientation between endorectal coils and TRUS probes. METHODS: Following pose correction by a RANSAC implementation of the ICP algorithm, TRUS and MRI Prostate contour points are represented by a 3D extension of the shape-context descriptor and matched by the Hungarian algorithm. Eventually, a smooth free-form warping is computed by fitting a 3D B-spline mesh to the set of matched points. RESULTS: Quantitative validation of the registration accuracy is provided on a retrospective set of ten real cases, using as landmarks either brachytherapy seeds (six cases) or external beam radiotherapy fiducials (four cases) implanted and visible in both modalities. The average registration error between the landmarks was 2.49 and 3.20 mm, for the brachytherapy and external beam sets, respectively, that is less than the MRI voxels' long axis length ([Formula: see text]). The overall average registration error (for brachytherapy and external beam datasets together) was 2.56 mm. CONCLUSIONS: The proposed method provides a promising framework for TRUS-MRI registration in focal prostate brachytherapy.