Faculty Bibliography

PURPOSE: The purpose of this review is to summarize the available data about the clinical and economic effectiveness of MRI in the diagnosis and management of prostate cancer and to provide practical recommendations for the use of MRI in the screening, diagnosis, staging and surveillance of prostate cancer. MATERIALS AND METHODS: A panel of clinicians with expertise in the diagnosis and management of prostate cancer evaluated the current published data regarding the use and effectiveness of MRI in the management of prostate cancer. For those clinical scenarios where adequate studies are available for analysis, recommendations are made on the basis of data; where such studies are not available; recommendations are made on the basis of expert consensus. RESULTS: At this time the data support the use of MRI for patients with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. The data regarding the utility of MRI for initial biopsy suggest a possible role for MRI in an initial biopsy in some circumstances. There is currently insufficient evidence to recommend MRI for screening, staging or surveillance of prostate cancer. CONCLUSION: MRI offers superior anatomic detail, the ability to evaluate cellular density based on water diffusion and blood flow based on contrast enhancement. MRI-targeted biopsy may increase the diagnosis of clinical significant cancers by identifying specific lesions not visible on conventional ultrasound. MRI adds cost to the management of prostate cancer. The clinical indications for the use of MRI in the management of prostate cancer are rapidly evolving.

BACKGROUND AND OBJECTIVE: Small kidney cancers are a heterogeneous group with varying malignant potential. Pathologic information obtained from a renal biopsy may guide decision-making for small kidney cancers. We sought to assess the effect of pathologic information from renal biopsy on the nonsurgical management of small kidney cancers in a population-based cohort of patients over 65 years of age. METHODS: In the Surveillance, Epidemiology and End Results-Medicare dataset, we identified patients >/=66 years diagnosed with a kidney cancer<4cm between 2002 and 2011. Diagnostic biopsy was defined by a Medicare claim within 1 month prior through 6 months following cancer diagnosis or before surgery. Nonsurgical management was defined by the absence of a claim for partial or radical nephrectomy or tumor ablation in the first 6 months following diagnosis. The relationship between patient and tumor characteristics and the likelihood of nonsurgical management by receipt of diagnostic biopsy was assessed by multivariable logistic regression models. RESULTS: From 8,933 patients, 2,782 (31%) had a diagnostic renal biopsy of whom 616 (22%) were managed nonsurgically. Controlling for patient, disease, and provider specialty, biopsy was associated with nonsurgical management (adjusted odds ratio = 1.61, 95% Cl: 1.43-1.82) in patients with low-grade tumors but also with more aggressive histology (clear cell renal cell carcinoma). Older age (85+) and geographic region were significantly associated with greater odds of diagnostic biopsy. Patients whose initial renal tumor diagnosis was made by a urologist (vs. other type of provider) were less likely to receive a biopsy (adjust odds ratio = 0.73, 95% Cl: 0.60-0.89). CONCLUSIONS: Although the use of renal biopsy has increased over time and is associated with the use of nonsurgical management of small kidney cancers, the use of the pathologic findings remains limited. Further advances, particularly with prognostic markers, are necessary before renal biopsy can be routinely implemented for treatment decision-making for small kidney cancers.

PURPOSE: To explore the role of whole-lesion apparent diffusion coefficient (ADC) analysis for predicting outcomes in prostate cancer patients on active surveillance. METHODS: This study included 72 prostate cancer patients who underwent MRI-ultrasound fusion-targeted biopsy at the initiation of active surveillance, had a visible MRI lesion in the region of tumor on biopsy, and underwent 3T baseline and follow-up MRI examinations separated by at least one year. Thirty of the patients also underwent an additional MRI-ultrasound fusion-targeted biopsy after the follow-up MRI. Whole-lesion ADC metrics and lesion volumes were computed from 3D whole-lesion volumes-of-interest placed on lesions on the baseline and follow-up ADC maps. The percent change in lesion volume on the ADC map between the serial examinations was computed. Statistical analysis included unpaired t tests, ROC analysis, and Fisher's exact test. RESULTS: Baseline mean ADC, ADC0-10th-percentile, ADC10-25th-percentile, and ADC25-50th-percentile were all significantly lower in lesions exhibiting >/=50% growth on the ADC map compared with remaining lesions (all P /=50% growth observed for ADC0-10th-percentile (585 +/- 308 vs. 911 +/- 336; P = 0.001). ADC0-10th-percentile achieved highest performance for predicting >/=50% growth (AUC = 0.754). Mean percent change in tumor volume on the ADC map was 62.3% +/- 26.9% in patients with GS >/= 3 + 4 on follow-up biopsy compared with 3.6% +/- 64.6% in remaining patients (P = 0.050). CONCLUSION: Our preliminary results suggest a role for 3D whole-lesion ADC analysis in prostate cancer active surveillance.

OBJECTIVE: To describe a novel technique of robotic inguinal lymphadenectomy with near infrared fluorescence imaging (NIRF) using indocyanine green (ICG) to facilitate lymph node identification during robotic groin dissection for penile cancer. MATERIALS AND METHODS: The patient is placed in lithotomy position with access to the groin. Three robotic ports and 1 assist port are placed in a V configuration below the tip of femoral triangle. Intradermal ICG is injected at the base of the penis (0.5 mL of 2 mg/kg concentration in normal saline), and the lymphatic channels and nodes are visualized using NIRF in the robotic console approximately 15 minutes after injection. The surgical template established in the open approach is then replicated using NIRF to ensure complete resection of the affected nodes. RESULTS: A total of 10 groin dissections in 5 patients have been completed using this technique, with an average lymph node yield of 7 per groin (range 5-13 lymph nodes). Mean operative time per groin was 207 minutes (range 164-258 minutes) and estimated blood loss was 38 mL (range 25-50 mL). Mean length of hospital stay was 1.8 days (range 0-4 days). Identification of the lymphatic drainage pattern from the superficial to deep groin nodes to pelvic nodes underneath the inguinal ligament was identified in all patients. With a mean follow-up of 10 months (range 3-16 months), there have been no postoperative infections, lymphatic leaks, wound breakdown, or necrosis. Pathologically involved lymph nodes were identified using NIRF. CONCLUSION: Our novel technique of robotic inguinal lymphadenectomy with fluorescence lymphangiography allows for identification and excision of both superficial and deep groin nodes with a significant reduction in morbidity compared with the open approach. Prospective studies are required to ensure long-term efficacy and results of this procedure.

Importance: Potential survival benefits from treating aggressive (Gleason score, >/=7) early-stage prostate cancer are undermined by harms from unnecessary prostate biopsy and overdiagnosis of indolent disease. Objective: To evaluate the a priori primary hypothesis that combined measurement of PCA3 and TMPRSS2:ERG (T2:ERG) RNA in the urine after digital rectal examination would improve specificity over measurement of prostate-specific antigen alone for detecting cancer with Gleason score of 7 or higher. As a secondary objective, to evaluate the potential effect of such urine RNA testing on health care costs. Design, Setting, and Participants: Prospective, multicenter diagnostic evaluation and validation in academic and community-based ambulatory urology clinics. Participants were a referred sample of men presenting for first-time prostate biopsy without preexisting prostate cancer: 516 eligible participants from among 748 prospective cohort participants in the developmental cohort and 561 eligible participants from 928 in the validation cohort. Interventions/Exposures: Urinary PCA3 and T2:ERG RNA measurement before prostate biopsy. Main Outcomes and Measures: Presence of prostate cancer having Gleason score of 7 or higher on prostate biopsy. Pathology testing was blinded to urine assay results. In the developmental cohort, a multiplex decision algorithm was constructed using urine RNA assays to optimize specificity while maintaining 95% sensitivity for predicting aggressive prostate cancer at initial biopsy. Findings were validated in a separate multicenter cohort via prespecified analysis, blinded per prospective-specimen-collection, retrospective-blinded-evaluation (PRoBE) criteria. Cost effects of the urinary testing strategy were evaluated by modeling observed biopsy results and previously reported treatment outcomes. Results: Among the 516 men in the developmental cohort (mean age, 62 years; range, 33-85 years) combining testing of urinary T2:ERG and PCA3 at thresholds that preserved 95% sensitivity for detecting aggressive prostate cancer improved specificity from 18% to 39%. Among the 561 men in the validation cohort (mean age, 62 years; range, 27-86 years), analysis confirmed improvement in specificity (from 17% to 33%; lower bound of 1-sided 95% CI, 0.73%; prespecified 1-sided P = .04), while high sensitivity (93%) was preserved for aggressive prostate cancer detection. Forty-two percent of unnecessary prostate biopsies would have been averted by using the urine assay results to select men for biopsy. Cost analysis suggested that this urinary testing algorithm to restrict prostate biopsy has greater potential cost-benefit in younger men. Conclusions and Relevance: Combined urinary testing for T2:ERG and PCA3 can avert unnecessary biopsy while retaining robust sensitivity for detecting aggressive prostate cancer with consequent potential health care cost savings.