Faculty Bibliography

PURPOSE: The objective of this study is to determine the natural history of pathologically benign multi-parametric MRI (mpMRI) cancer suspicious regions (CSR) following targeted biopsy. MATERIALS AND METHODS: Between January 2012 and September 2014, 330 men underwent prostate mpMRI. 533 CSRs were identified and scored on a Likert scale of 1-5 based on suspicion for malignancy (5=highest suspicion level). Following mpMRI, all men underwent MRI-US fusion-targeted prostate biopsy using the Profuse software and ei-Nav|Artemis system and a computer-generate 12-core random biopsy. This study analyzes a cohort of 34 men with 51 CSRs with benign prostate biopsies who underwent repeat mpMRI and PSA testing at one year. Changes in greatest linear measurement (GLM), suspicion score (ss) and serum PSA were ascertained. RESULTS: Over one year, both the ss distribution and mean GLM of the CSRs decreased significantly (p<0.0001), while mean PSA did not significantly change (p=0.632). Overall, 2 (3.9%), 15 (29.4%) and 34 (66.7%) CSRs showed an increase, no change or decrease in ss, respectively. None (0%), 21 (42.0%) and 29 (58.0%) showed an increase (>/=20%), no change or decrease (>/=20%) in GLM, respectively. Of the two CSRs exhibiting increases in ss, neither showed a PSA increase >/=0.5 ng/mL. CONCLUSIONS: Our study provides compelling evidence that few benign CSRs increase in ss and/or GLM within one year, independent of baseline ss. Therefore, routinely repeating the mpMRI at one year in men with pathologically benign CSRs should be discouraged since it is unlikely to influence management decisions.

PURPOSE: The aim of this study was to compare coregistration of the bladder wall, bladder masses, and pelvic lymph nodes between sequential and simultaneous PET and MRI acquisitions obtained during hybrid F-FDG PET/MRI performed using a diuresis protocol in bladder cancer patients. METHODS: Six bladder cancer patients underwent F-FDG hybrid PET/MRI, including IV Lasix administration and oral hydration, before imaging to achieve bladder clearance. Axial T2-weighted imaging (T2WI) was obtained approximately 40 minutes before PET ("sequential") and concurrently with PET ("simultaneous"). Three-dimensional spatial coordinates of the bladder wall, bladder masses, and pelvic lymph nodes were recorded for PET and T2WI. Distances between these locations on PET and T2WI sequences were computed and used to compare in-plane (x-y plane) and through-plane (z-axis) misregistration relative to PET between T2WI acquisitions. RESULTS: The bladder increased in volume between T2WI acquisitions (sequential, 176 [139]mL; simultaneous, 255 [146]mL). Four patients exhibited a bladder mass, all with increased activity (SUV, 9.5-38.4). Seven pelvic lymph nodes in 4 patients showed increased activity (SUV, 2.2-9.9). The bladder wall exhibited substantially less misregistration relative to PET for simultaneous, compared with sequential, acquisitions in in-plane (2.8 [3.1]mm vs 7.4 [9.1]mm) and through-plane (1.7 [2.2]mm vs 5.7 [9.6]mm) dimensions. Bladder masses exhibited slightly decreased misregistration for simultaneous, compared with sequential, acquisitions in in-plane (2.2 [1.4]mm vs 2.6 [1.9]mm) and through-plane (0.0 [0.0]mm vs 0.3 [0.8]mm) dimensions. FDG-avid lymph nodes exhibited slightly decreased in-plane misregistration (1.1 [0.8]mm vs 2.5 [0.6]mm), although identical through-plane misregistration (4.0 [1.9]mm vs 4.0 [2.8]mm). CONCLUSIONS: Using hybrid PET/MRI, simultaneous imaging substantially improved bladder wall coregistration and slightly improved coregistration of bladder masses and pelvic lymph nodes.

BACKGROUND: The objectives of the present study were to report the incidence of pathologic T3a upstaging in a contemporary cohort of patients with clinical stage T1 (cT1) renal tumors treated with partial or radical nephrectomy; investigate the clinical outcomes; and identify the predictors associated with pathologic upstaging. MATERIALS AND METHODS: From a single-institution, institutional review board-approved renal tumor database of 945 patients, we identified 610 patients who had undergone surgery for a cT1 renal mass. Data for 494 patients were available for analysis. Of these, 66 lesions had been pathologically upstaged to T3a after surgery and 428 had not. The oncologic follow-up data and clinical and pathologic features were recorded, and multivariable logistic regression analysis was performed to identify the risk factors for pT3a upstaging, controlling for age, gender, body mass index, and nephrectomy type. RESULTS: The cT1 tumors of 66 patients (13.3%) were upstaged to pT3a after surgery. Of these 66 patients, 44 (66.7%) had undergone partial and 22 (33.3%) radical nephrectomy. The median follow-up period was 50 months. No patient with upstaging developed recurrence, and all were disease free at their last follow-up visit. On multivariable analysis, tumor size > 4 cm (odds ratio [OR], 3.766; 95% confidence interval [CI], 1.417-10.011; P < .008), clear cell histologic features (OR, 4.461; 95% CI, 1.498-13.461; P < .007), and positive surgical margins (hazard ratio, 5.118; 95% CI, 2.088-12.547; P < .0001) were associated with upstaging. CONCLUSION: Of the cT1 lesions in 66 patients, 13% were pathologically upstaged after surgery. The patients with larger tumors, clear cell histologic features, and positive surgical margins were at the greatest risk of upstaging. However, after an intermediate follow-up period, pathologic upstaging did not appear to result in worsened oncologic outcomes.

PURPOSE: The impact of cardiopulmonary bypass in level III-IV tumor thrombectomy on surgical and oncologic outcomes is unknown. We determine the impact of cardiopulmonary bypass on overall and cancer specific survival, as well as surgical complication rates and immediate outcomes in patients undergoing nephrectomy and level III-IV tumor thrombectomy with or without cardiopulmonary bypass. MATERIALS AND METHODS: We retrospectively analyzed 362 patients with renal cell cancer and with level III or IV tumor thrombus from 1992 to 2012 at 22 U.S. and European centers. Cox proportional hazards models were used to compare overall and cancer specific survival between patients with and without cardiopulmonary bypass. Perioperative mortality and complication rates were assessed using logistic regression analyses. RESULTS: Median overall survival was 24.6 months in noncardiopulmonary bypass cases and 26.6 months in cardiopulmonary bypass cases. Overall survival and cancer specific survival did not differ significantly in both groups on univariate analysis or when adjusting for known risk factors. On multivariate analysis no significant differences were seen in hospital length of stay, Clavien 1-4 complication rate, intraoperative or 30-day mortality and cancer specific survival. Limitations include the retrospective nature of the study. CONCLUSIONS: In our multi-institutional analysis the use of cardiopulmonary bypass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Neither approach was independently associated with increased mortality on multivariate analysis. Greater surgical complications were not independently associated with the use of cardiopulmonary bypass.

IMPORTANCE: With the significant downward size and stage migration of localized kidney cancers, the management options for small kidney cancers have expanded and evolved. OBJECTIVE: To describe trends and outcomes in the management of small kidney cancers in the first decade of the new millennium. DESIGN, SETTING, AND PARTICIPANTS: Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked to Medicare claims were used to identify patients 66 years or older with a pathologically confirmed small kidney cancer (<4 cm) diagnosed between January 1, 2001, and December 31, 2009; analysis was performed between February 1, 2014, and December 31, 2014. Multivariable logistic regression was used to assess the likelihood of nonsurgical management vs surgical intervention. Cox proportional hazards regression was used to assess the relationships between treatment approach and overall and cancer-specific survival. The effect of treatment approach on cancer-specific survival was analyzed in a competing risks framework. MAIN OUTCOMES AND MEASURES: The likelihood of receiving no surgery vs surgical intervention as a function of demographic and disease characteristics, as well as the relationships between treatment approach and overall and cancer-specific survival. RESULTS: Of 6664 patients, 5994 individuals (90.0%) had surgical treatment; the care of 670 patients (10.0%) was managed nonsurgically. Use of radical nephrectomy decreased over time (from 69.0% to 42.5%), and the use of nephron-sparing surgery (partial nephrectomy and ablation) increased (from 21.5% to 49.0%); the proportion of patients who did not undergo surgery remained stable (9.5% and 8.5%). During a median follow-up of 63 months (interquartile range, 43-89 months) (follow-up for vital status through December 31, 2011), 2119 patients (31.8%) patients died, including 293 individuals (4.4%) of kidney cancer. Although overall survival was better in patients who received surgical treatment, only nephron-sparing surgery was associated with a benefit in cancer-specific survival (adjusted hazard ratio, 0.47; 95% CI, 0.31-0.69; P < .001). CONCLUSIONS AND RELEVANCE: Surgery continues to be the most common treatment for patients with small kidney cancers. The use of nephron-sparing surgery exceeds radical nephrectomy in patients who receive surgery. Although our findings suggest that nonsurgical management is acceptable for certain patients, use of this approach remains low.