Faculty Bibliography

We convened a multidisciplinary expert panel to make recommendations on current utility and future research needs for post-diagnosis prostate cancer biomarkers. The San Francisco Consensus Statement reflects on the rapid recent progress achieved, and the substantial work still ahead.

BACKGROUND:Magnetic resonance imaging (MRI) of the prostate after a prior negative biopsy may reduce the need for unnecessary repeat biopsies. OBJECTIVE:To externally validate a previously developed nomogram predicting benign prostate pathology on MRI/ultrasound (US) fusion-targeted biopsy in men with a Prostate Imaging Reporting and Data System (PI-RADS) 3-5 region of interest and a prior negative 12-core systematic biopsy, and update this nomogram to improve its performance. DESIGN, SETTING, AND PARTICIPANTS/METHODS:A total of 2063 men underwent MRI/US fusion-targeted biopsy from April 2012 to September 2017; 104 men with a negative systematic biopsy followed by MRI-US fusion-targeted biopsy of a PI-RADS 3-5 region of interest (58%) met the study inclusion criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS/UNASSIGNED:An MRI-based nomogram that had previously been developed in a multi-institutional clinical setting was externally validated. Predictive characteristics were age, prostate volume, MRI PI-RADS score, and prostate-specific antigen (PSA). Bayesian logistic regression was used to update the previous model. RESULTS AND LIMITATIONS/CONCLUSIONS:Median age of the external validation cohort was 68 yr, PSA was 7.2ng/ml, and biopsy confirmed benign pathology in 30% (n=31), suggesting a lower baseline risk compared with the nomogram development cohort. Receiver operating characteristic curve analysis showed areas under curve (AUCs) from 0.77 to 0.80 for nomogram validation. An updated model was constructed with improved calibration and similar discrimination (AUC 0.79). CONCLUSIONS:Age, prostate volume, PI-RADS, and PSA predict benign pathology on MRI/US fusion-targeted biopsy in men with a prior negative 12-core systematic biopsy. The validated and updated nomogram demonstrated high diagnostic accuracy and may further aid in the decision to avoid a biopsy in men with a prior negative biopsy. PATIENT SUMMARY/UNASSIGNED:We externally validated a clinically useful tool that predicts benign prostate pathology on magnetic resonance imaging/ultrasound fusion-targeted biopsy in men with a prior negative 12-core systematic biopsy and updated this predictive tool to improve its performance in patient counseling regarding the need for a repeat biopsy.

OBJECTIVES/OBJECTIVE:To evaluate the impact of cisplatin-based neoadjuvant chemotherapy (NAC) in patients who underwent nephroureterectomy for high grade (HG) upper tract urothelial carcinoma (UTUC). METHODS:Retrospective review was conducted of patients with HG UTUC from 2011 to 2017 who underwent nephroureterectomy at two institutions. Patients with eGFR > 50 mL/min/1.73m2 were considered eligible for NAC and were referred for evaluation of NAC prior to nephroureterectomy. Patient demographics, kidney function, clinical and pathologic response rates and outcomes were analyzed. RESULTS:Of 95 patients with HG UTUC meeting inclusion criteria (mean age 72.3 years, mean pre-op eGFR 57.0 mL/min/1.73m2), 61 patients were considered eligible for NAC with eGFR > 50 mL/min/1.73m2, of which 25 (41%) received NAC. Of the patients who received NAC, 80% (20/25) of patients had clinical response on imaging and 80% (20/25) had pathologic response (<pT2N0 disease) on nephroureterectomy. On final pathology, only 20% of the NAC group had ≥pT2 disease compared to 64% of patients who proceeded directly to surgery (p = 0.001). Patients who received NAC had significantly longer progression free survival (p=0.051) and overall survival (p=0.052) compared to patients who proceeded directly to surgery. No patients progressed or were deemed ineligible for surgery due to NAC. CONCLUSIONS:Cisplatin-based NAC demonstrated a high clinical and pathologic response rate in patients with HG UTUC without compromising definitive surgical treatment. Since nephroureterectomy significantly reduces kidney function and eligibility for cisplatin-based chemotherapy after surgery, patients with HG UTUC should be considered for NAC.