Faculty Bibliography

Purpose Pre-operative three-dimensional (3D) printed renal malignancy models are tools with potential benefits in surgical training and patient education [1,2]. Most importantly, 3D models may facilitate surgical planning by allowing surgeons to assess tumor complexity as well as the relationship of the tumor to major anatomic structures [3]. The objective of this study was to evaluate this impact. Methods Imaging was obtained from an IRB approved, prospectively collected database of multiparametric magnetic resonance imaging (MRI) of renal masses. Ten cases eligible for elective partial nephrectomy were retrospectively selected. High-fidelity models were 3D printed in multiple colors based on T1 images (Fig. 1). Cases were reviewed by three attending surgeons and six senior residents with imaging alone and in addition to the 3D model. A standardized questionnaire was developed to capture the planned surgical approach and intraoperative technique in both sessions. Results Surgical approach was changed in 20 % of decisions, intraoperative considerations were changed in 40 % (Fig. 2). Thirty percent and 23 % of decisions in the attending and resident groups, respectively, were altered by the 3D model. Overall, every case was modified with this additional information. All participants reported that the models helped plan the surgical approach for partial nephrectomy. Most reported improved comprehension of anatomy and confidence in surgical plan. Half reported that the 3D printed model altered their surgical plan significantly. Due to use of T1 images, reconstruction of calyces and tertiary blood vessels were limited: 8 of the 9 participants desired more information regarding these structures. (Figure presented) Conclusion Utilization of 3D modeling may aid in pre-operative and intra-operative planning for both attending and resident surgeons. While 3D models with MR imaging is feasible, computed tomography (CT) imaging may provide additional anatomical information. Future study is required to prospectively assess the utility of models and pre-operative planning and intra-operative guidance

INTRODUCTION & OBJECTIVES: The presence of venous tumour thrombus (VTT) in advanced renal cell carcinoma (RCC) makes clinical and surgical management challenging. Preoperative embolization has been used as a complementary intervention to facilitate surgical resection of complex renal tumours. Our objective is to analyse surgical and clinical outcomes in those patients with renal artery embolization (RAE) previous to oncological surgery. MATERIAL & METHODS: A total of 1380 patients with diagnosis of RCC with VTT from 1972 to 2014 from 22 Centers in the United States and Europe were retrospectively analysed. We compare those patients undergoing surgery with or without previous RAE. A univariable analysis was performed for surgery time, intraoperative bleeding, number of blood units transfused, length of hospital stay and presence of complications. RESULTS: 256 patients out of 1380 underwent RAE prior to radical nephrectomy and tumour trombectomy. CONCLUSIONS: A longer hospital stay with a higher intraoperative bleeding, need of blood transfusion and presence of surgical complications are seen on preoperative RAE patients. Further analysis are needed to finally confirm this data.(Table Presented)

INTRODUCTION & OBJECTIVES: Evidence suggests an inverse relation between hospital volume and perioperative outcomes. RCC with venous extension represents a challenging surgical setting with major complication rates of 13% to 36% and perioperative mortality of 10% mainly determined by the level of thrombus. We aimed to analyze the impact of hospital volume on perioperative outcomes in a multi-center cohort of RCC with venous extension. MATERIAL & METHODS: We retrospectively reviewed 2552 patients from a multi-institutional collaborative database (23 centers) who underwent nephrectomy and tumor thrombectomy from 1971-2014. Centers were classified as low volume (LV, < 3 cases/y), medium volume (MV, 4-7 cases/y) and high volume (HV, > 8 cases/y). Perioperative complications were reported using the Clavien-Dindo grading system. Univariable and multivariable analyses were performed by logistic and Cox proportional hazards regression models, to assess adjusted outcomes of LV, MV and HV centers. Two-sided p value <0.05 was considered statistically significant, SPSS 18.0 software were used. RESULTS: Seven, 10 and 6 centers were classified as LV, MV and HV, respectively. We selected 2521 patients who had data for the present analysis, 327 from LV, 810 from MV and 1384 from HV centers. Mean age at surgery was 62,7 +/- 11,4 years. Median Charlson comorbidity-index was higher for LV (5) and MV (6) vs. HV (3), (p<0,001). Level of the tumor thrombus according to the Mayo Clinic classification was higher for MV (p=0,007), with 30%, 39% and 33% having levels > III. Overall complications were recorded in 75%, 55% and 53%, and major complications (Clavien > 3) were observed in 32%, 33% and 15% for LV, MV and HV. Thirty-day perioperative mortality occurred in 20 (6%), 64 (8%) and 37 (3%) patients from LV, MV and HV, respectively. On multivariate analysis hospital volume was an independent predictor of overall (p<0,001) and major (p=0,008) complications, once adjusted for age, Charlson CI, ECOG-PS, clinical stage, thrombus level, preoperative embolization, liver mobilization, Pringle manoeuvre, extended LND and pathologic stage. Charlson CI, ECOG-PS and clinical stage were independently associated with increased risk of perioperative mortality. CONCLUSIONS: Hospital volume was inversely associated with increased risk of overall and perioperative complications. Patients from medium volume centers had worse clinical and pathological features. No association between hospital volume and 30-d perioperative mortality was found

PURPOSE: The aim of this study was to evaluate multisequence magnetic resonance imaging (MRI) in detecting local recurrence after transurethral resection for bladder cancer. METHODS: Thirty-six patients with bladder cancer with previous transurethral resection underwent bladder MRI incorporating T2-weighted imaging, diffusion-weighted imaging, and delayed contrast-enhanced T1-weighted imaging, followed by cystoscopy. Two radiologists (R1 and R2) evaluated examinations for suspicious findings. RESULTS: Forty-seven percent of patients had recurrent tumor at cystoscopy and biopsy. Using multisequence MRI, sensitivity and specificity were 67% and 81% for R1 and 73% and 62% for R2. Both readers missed 1 high-grade pathologic stage T1 recurrent tumor; otherwise, all missed tumors were low-grade pathologic stage Ta lesions. All false positives for R1 and 7 of 9 false positives for R2 were in patients receiving previous bacillus Calmette-Guerin therapy. Furthermore, 40% to 50% of solitary abnormalities and 83% to 100% of multifocal abnormalities were tumor recurrences; 12% to 20% of smooth wall thickening, 50% to 75% of irregular wall thickening, and 88% to 100% of papillary masses were tumor recurrences. CONCLUSIONS: Although multisequence MRI exhibited moderate performance for detecting recurrent tumor, nearly all missed tumors were low grade and noninvasive.

BACKGROUND: Increasing evidence supports the use of magnetic resonance imaging (MRI)-ultrasound fusion-targeted prostate biopsy (MRF-TB) to improve the detection of clinically significant prostate cancer (PCa) while limiting detection of indolent disease compared to systematic 12-core biopsy (SB). OBJECTIVE: To compare MRF-TB and SB results and investigate the relationship between biopsy outcomes and prebiopsy MRI. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a prospectively acquired cohort of men presenting for prostate biopsy over a 26-mo period. A total of 601 of 803 consecutively eligible men were included. INTERVENTIONS: All men were offered prebiopsy MRI and assigned a maximum MRI suspicion score (mSS). Men with an MRI abnormality underwent combined MRF-TB and SB. OUTCOMES: Detection rates for all PCa and high-grade PCa (Gleason score [GS] >/=7) were compared using the McNemar test. RESULTS AND LIMITATIONS: MRF-TB detected fewer GS 6 PCas (75 vs 121; p<0.001) and more GS >/=7 PCas (158 vs 117; p<0.001) than SB. Higher mSS was associated with higher detection of GS >/=7 PCa (p<0.001) but was not correlated with detection of GS 6 PCa. Prediction of GS >/=7 disease by mSS varied according to biopsy history. Compared to SB, MRF-TB identified more GS >/=7 PCas in men with no prior biopsy (88 vs 72; p=0.012), in men with a prior negative biopsy (28 vs 16; p=0.010), and in men with a prior cancer diagnosis (42 vs 29; p=0.043). MRF-TB detected fewer GS 6 PCas in men with no prior biopsy (32 vs 60; p<0.001) and men with prior cancer (30 vs 46; p=0.034). Limitations include the retrospective design and the potential for selection bias given a referral population. CONCLUSIONS: MRF-TB detects more high-grade PCas than SB while limiting detection of GS 6 PCa in men presenting for prostate biopsy. These findings suggest that prebiopsy multiparametric MRI and MRF-TB should be considered for all men undergoing prostate biopsy. In addition, mSS in conjunction with biopsy indications may ultimately help in identifying men at low risk of high-grade cancer for whom prostate biopsy may not be warranted. PATIENT SUMMARY: We examined how magnetic resonance imaging (MRI)-targeted prostate biopsy compares to traditional systematic biopsy in detecting prostate cancer among men with suspicion of prostate cancer. We found that MRI-targeted biopsy detected more high-grade cancers than systematic biopsy, and that MRI performed before biopsy can predict the risk of high-grade cancer.

OBJECTIVE: The purpose of this study was to determine whether qualitative and quantitative MRI feature analysis is useful for differentiating type 1 from type 2 papillary renal cell carcinoma (PRCC). MATERIALS AND METHODS: This retrospective study included 21 type 1 and 17 type 2 PRCCs evaluated with preoperative MRI. Two radiologists independently evaluated various qualitative features, including signal intensity, heterogeneity, and margin. For the quantitative analysis, a radiology fellow and a medical student independently drew 3D volumes of interest over the entire tumor on T2-weighted HASTE images, apparent diffusion coefficient parametric maps, and nephrographic phase contrast-enhanced MR images to derive first-order texture metrics. Qualitative and quantitative features were compared between the groups. RESULTS: For both readers, qualitative features with greater frequency in type 2 PRCC included heterogeneous enhancement, indistinct margin, and T2 heterogeneity (all, p < 0.035). Indistinct margins and heterogeneous enhancement were independent predictors (AUC, 0.822). Quantitative analysis revealed that apparent diffusion coefficient, HASTE, and contrast-enhanced entropy were greater in type 2 PRCC (p < 0.05; AUC, 0.682-0.716). A combined quantitative and qualitative model had an AUC of 0.859. Qualitative features within the model had interreader concordance of 84-95%, and the quantitative data had intraclass coefficients of 0.873-0.961. CONCLUSION: Qualitative and quantitative features can help discriminate between type 1 and type 2 PRCC. Quantitative analysis may capture useful information that complements the qualitative appearance while benefiting from high interobserver agreement.

Purpose: Percutaneous thermal ablation (PTA) is a minimally-invasive, nephron-sparing alternative to surgery for patients with small renal cancers. We examined short- and long-term complications and disease-specific survival in older adults with small renal cancers who received partial (PN) nephrectomy, radical nephrectomy (RN) or PTA. Materials: In the linked Surveillance, Epidemiology and End Results-Medicare dataset we identified patients age 66 or older who received PN, RN or PTA within 6 months of diagnosis of a clinically-staged T1a renal cancer in 2006-2011. Follow-up for survival and cause of death was available through 2012. Complications assessed at 30 days and 31-365 days post procedure based on Medicare claims included renal insufficiency and periprocedural and cardiovascular complications. Associations between procedure type and complications were estimated in propensity score-matched logistic regression models. Associations with cancer-specific survival (CSS) were estimated in propensity score-adjusted, competing-risk models. Results: There were 4,508 patients with cT1a renal cancer, of whom 469 (10%) had PTA, 1,673 (37%) PN and 2,366 (53%) RN. Patients who had PTA were older and had greater comorbidity than those treated surgically (p<0.0001). At 30 days, rates of acute renal failure, structural kidney injury, cardiovascular complications and other periprocedural complications were significantly lower with PTA than PN or RN (adjusted odds ratios [AOR] 0.10-0.52, p<0.05). Rates of cardiovascular and renal structural complications at 1 year were similar across procedure types. PTA was associated with a lower risk of renal insufficiency in days 31-365 compared with RN (AOR 0.56, 95% CI 0.34-0.93, p< 0.05), but not with PN. At 46 months median follow-up, there were 112 deaths due to kidney cancer. Cancer-specific survival did not vary by procedure type. Conclusions: In a population-based cohort of older adults, PTA was associated with a lower risk of early complications than RN or PN, and a lower rate of long-term renal insufficiency than RN. PTA may be safer than surgery for well-selected patients, with no detriment to oncologic outcomes at nearly 4 years median follow-up

BACKGROUND: To assess associations between whole-lesion apparent diffusion coefficient (ADC) metrics and pathologic findings of Likert score 3 prostate lesions at MRI/ultrasound fusion targeted biopsy. METHODS: This retrospective Institutional Review Board-approved study received a waiver of consent. We identified patients receiving a highest lesion score of 3 on 3 Tesla multiparametric MRI reviewed by a single experienced radiologist using a 5-point Likert scale and who underwent fusion biopsy. A total of 188 score 3 lesions in 158 patients were included. Three-dimensional volumes-of-interest encompassing each lesion were traced on ADC maps. Logistic regression was used to predict biopsy results based on whole-lesion ADC metrics and patient biopsy history. Biopsy yield was compared between metrics. RESULTS: By lesion, targeted biopsy identified tumor in 22.3% and Gleason score (GS) > 6 tumor in 8.5%, although results varied by biopsy history: biopsy-naive (n = 80), 20.0%/8.8%; prior negative biopsy (n = 53), 9.4%/1.9%; prior positive biopsy (n = 55): 40.0%/14.5%. Biopsy history, whole-lesion mean ADC, whole-lesion ADC10-25 , and whole-lesion ADC25-50 were each significantly associated with tumor or GS > 6 tumor at fusion biopsy (P 6 tumor, which was significantly higher (P < 0.001) than specificity of PSA (17.5%) at identical sensitivity. CONCLUSION: For score 3 lesions in patients without prior negative biopsy, whole-lesion ADC metrics help detect GS > 6 cancer while avoiding negative biopsies. However, deferral of fusion biopsy may be considered for score 3 lesions in patients with prior negative biopsy (without applying whole-lesion ADC metrics) given exceedingly low ( approximately 2%) frequency of GS > 6 tumor in this group. J. Magn. Reson. Imaging 2015.