Advances in medical imaging for the diagnosis and management of common genitourinary cancers

Neighborhood social vulnerability and disparities in time to kidney cancer surgical treatment and survival in Arizona

BACKGROUND

Hispanics and American Indians (AI) have high kidney cancer incidence and mortality rates in Arizona. This study assessed: (1) whether racial and ethnic minority patients and patients from neighborhoods with high social vulnerability index (SVI) experience a longer time to surgery after clinical diagnosis, and (2) whether time to surgery, race and ethnicity, and SVI are associated with upstaging to pT3/pT4, disease-free survival (DFS), and overall survival (OS).

METHODS

Arizona Cancer Registry (2009-2018) kidney and renal pelvis cases (n = 4592) were analyzed using logistic regression models to assess longer time to surgery and upstaging. Cox-regression hazard models were used to test DFS and OS.

RESULTS

Hispanic and AI patients with T1 tumors had a longer time to surgery than non-Hispanic White patients (median time of 56, 55, and 45 days, respectively). Living in neighborhoods with high (≥75) overall SVI increased odds of a longer time to surgery for cT1a (OR 1.54, 95% CI: 1.02-2.31) and cT2 (OR 2.32, 95% CI: 1.13-4.73). Race and ethnicity were not associated with time to surgery. Among cT1a patients, a longer time to surgery increased odds of upstaging to pT3/pT4 (OR 1.95, 95% CI: 0.99-3.84). A longer time to surgery was associated with PFS (HR 1.52, 95% CI: 1.17-1.99) and OS (HR 1.63, 95% CI: 1.26-2.11). Among patients with cT2 tumor, living in high SVI neighborhoods was associated with worse OS (HR 1.66, 95% CI: 1.07-2.57).

CONCLUSIONS

High social vulnerability was associated with increased time to surgery and poor survival after surgery.

Liquid biopsies for detection, surveillance, and prognosis of urothelial cancer: a future standard?

INTRODUCTION

Liquid biopsies are used for the detection of tumor-specific elements in body fluid. Their application in prognosis and diagnosis of muscle/non-muscle invasive bladder cancer (MIBC/NMIBC) or upper tract urothelial cancer (UTUC) remains poorly known and rarely mentioned in clinical guidelines.

AREAS COVERED

Herein, we provide an overview of current data regarding the use of liquid biopsies in urothelial tumors.

EXPERT OPINION

Studies that were included analyzed liquid biopsies using the detection of circulating tumor cells (CTCs), deoxyribonucleic acid (DNA), ribonucleic acid (RNA), exosomes, or metabolomics. The sensitivity of blood CTC detection in patients with localized cancer was 35% and raised to 50% in patients with metastatic cancer. In NMIBC patients, blood CTC was associated with poor prognosis, whereas discrepancies were seen in MIBC patients. Circulating plasma DNA presented a superior sensitivity to urine and was a good indicator for diagnosis, follow-up, and oncological outcome. In urine, specific bladder cancer (BC) microRNA had an overall sensitivity of 85% and a specificity of 86% in the diagnosis of urothelial cancer. These results are in favor of the use of liquid biopsies as biomarkers for in urothelial cancer management.

Contemporary Clinical Definitions, Differential Diagnosis, and Novel Predictive Tools for Renal Cell Carcinoma

Despite significant progress regarding clinical detection/imaging evaluation modalities and genetic/molecular characterization of pathogenesis, advanced renal cell carcinoma (RCC) remains an incurable disease and overall RCC mortality has been steadily rising for decades. Concomitantly, clinical definitions have been greatly nuanced and refined. RCCs are currently viewed as a heterogeneous series of cancers, with the same anatomical origin, but fundamentally different metabolisms and clinical behaviors. Thus, RCC pathological diagnosis/subtyping guidelines have become increasingly intricate and cumbersome, routinely requiring ancillary studies, mainly immunohistochemistry. Meanwhile, RCC-associated-antigen targeted systemic therapy has been greatly diversified and emerging, novel clinical applications for RCC immunotherapy have already reported significant survival benefits, at least in the adjuvant setting. Even so, systemically disseminated RCCs still associate very poor clinical outcomes, with currently available therapeutic modalities only being able to prolong survival. In lack of a definitive cure for advanced RCCs, integration of the amounting scientific knowledge regarding RCC pathogenesis into RCC clinical management has been paramount for improving patient outcomes. The current review aims to offer an integrative perspective regarding contemporary RCC clinical definitions, proper RCC clinical work-up at initial diagnosis (semiology and multimodal imaging), RCC pathological evaluation, differential diagnosis/subtyping protocols, and novel clinical tools for RCC screening, risk stratification and therapeutic response prediction.

[Modern tomography imaging techniques in urological diseases]

BACKGROUND

Radiologic imaging is important for the detection, staging and follow-up of urological tumors. Basic therapy decisions for both oncological (surgical vs. systemic therapy, e.g. in testicular cancer) and non-oncological pathologies (interventional vs. conservative therapy, e.g. for ureteral stones) depend largely on the tomographic imaging performed. Due to its almost ubiquitous availability, speed and cost-effectiveness, computed tomography (CT) plays an important role not only in the clarification of abdominal trauma and non-traumatic emergencies, but also in staging and follow-up of oncological patients. However, the level of radiation exposure, impaired renal function and allergies to iodinated contrast media limit the use of CT. Magnetic resonance imaging (MRI) can be a good alternative for many areas of application in oncological and non-oncological imaging due to its high soft tissue differentiation and functional-specific protocols but without the use of ionizing radiation.

AIM

In the following, the main indications of abdominal and pelvic CT and MRI in urology and their limitations are summarized.

RESULTS

The areas of application between CT and MRI are increasingly overlapping, since the latest developments in CT continue to further reduce radiation exposure and increase contrast information, while the speed and robustness of MRI are significantly improving at the same time.

Head-to-head comparison of [68 Ga]Ga-P16-093 and [68 Ga]Ga-PSMA-617 in dynamic PET/CT evaluation of the same group of recurrent prostate cancer patients

PURPOSE

This study was prospectively designed to evaluate the early dynamic organ distribution and tumor detection capability of [⁶⁸ Ga]Ga-P16-093, which was compared with [⁶⁸ Ga]Ga-PSMA-617 in the same group of recurrent prostate cancer patients.

METHODS

Twenty patients with recurrent prostate cancer were enrolled. In 2 consecutive days, each patient underwent a 60-min dynamic PET/CT scan after intravenous administration of 148-185 MBq (4-5 mCi) [⁶⁸ Ga]Ga-P16-093 and [⁶⁸ Ga]Ga-PSMA-617, respectively. Following a low-dose CT scan, serial dynamic PET scans were performed from head to proximal thigh at 9 time points (30 s/bed at 4, 7, 10, 13, and 16 min; 1 min/bed at 20, 30, and 45 min; and 2 min/bed at 60 min). Standardized uptake values were measured for semi-quantitative comparison.

RESULTS

[⁶⁸ Ga]Ga-P16-093 PET/CT revealed a significantly higher tumor uptake at 4 min (SUVmax 7.88 ± 5.26 vs. 6.01 ± 3.88, P < 0.001), less blood pool retention at 4 min (SUVmean 5.12 ± 1.16 vs. 6.14 ± 0.98, P < 0.001), and lower bladder accumulation at 60 min (SUVmean 31.33 ± 27.47 vs. 48.74 ± 34.01, P = 0.042) than [⁶⁸ Ga]Ga-PSMA-617 scan. Significantly higher [⁶⁸ Ga]Ga-P16-093 uptakes were also observed in the parotid gland, liver, spleen, and kidney. Besides, [⁶⁸ Ga]Ga-P16-093 exhibited a better detectability of tumor than [⁶⁸ Ga]Ga-PSMA-617 (366 vs. 321, P = 0.009).

CONCLUSIONS

[⁶⁸ Ga]Ga-P16-093 showed advantages over [⁶⁸ Ga]Ga-PSMA-617 with higher tumor uptakes, tumor-to-blood pool ratio and detection capability, less blood pool, and bladder accumulation in recurrent prostate cancer patients.

TRIAL REGISTRATION

[⁶⁸ Ga]Ga-P16-093 and [⁶⁸ Ga]Ga-PSMA-617 PET/CT Imaging in the Same Group of Prostate Cancer Patients (NCT04796467, Registered 12 March 2021, retrospectively registered) URL of registry: https://clinicaltrials.gov/ct2/show/NCT04796467.

Utility of 18F-Fluciclovine PET/MRI for Staging Newly Diagnosed High-Risk Prostate Cancer and Evaluating Response to Initial Androgen Deprivation Therapy: A Prospective Single-Arm Pilot Study

BACKGROUND. Despite advances in prostate cancer treatment, rates of biochemical recurrence remain high, relating to lack of detection of small-volume metastatic disease using conventional imaging for initial staging. OBJECTIVE. The purpose of this study was to assess the potential use of 18F-fluciclovine PET/MRI for initial staging of high-risk prostate cancer and evaluating response to androgen deprivation therapy (ADT). METHODS. This prospective clinical trial enrolled 14 men with newly diagnosed high-risk prostate cancer and negative or equivocal conventional staging imaging for metastatic disease between January 2018 and February 2019. All patients underwent pretreatment 18F-fluciclovine PET/MRI including multiparametric prostate MRI; 12 underwent 18F-fluciclovine PET/MRI after surgery or between ADT and radiotherapy. Confidence in identification of the primary intraprostatic lesion and nodal metastases was independently rated on a 0-3 Likert scale by three readers with nuclear medicine experience for 18F-fluciclovine PET/MRI and three readers with abdominal imaging experience for MRI alone. Findings scored as 2 or 3 by at least two readers of a given modality were considered positive. A single reader measured SUVmean, SUVmax, and volume of the MRI-defined intraprostatic lesion and SUVmax of suspicious lymph nodes on PET before and after initiation of ADT. Changes in SUV were analyzed using nonparametric Wilcox-on signed-rank tests. RESULTS. The biopsy-proven lesion in the prostate gland was accurately identified in all 14 patients on both MRI and 18F-fluciclovine PET/MRI. Suspected nodal metastases were detected in three patients on MRI and seven patients on 18F-fluciclovine PET/MRI. After ADT, all patients showed decreased activity within the intraprostatic lesion and/or all suspicious lymph nodes. The primary lesion SUVmean was 4.5 ± 1.1 (range, 2.7-6.5) before treatment and 2.4 ± 1.1 (range, 0.0-3.6) after initiation of ADT (p = .008). For suspicious lymph nodes, the pretreatment SUVmax was 5.5 ± 3.7 (range, 2.8-12.7) and the post-treatment SUVmax was 2.8 ± 1.4 (range, 1.4-5.5) (p = .03). CONCLUSION.18F-labeled fluciclovine PET/MRI shows potential utility in initial staging of high-risk prostate cancer and in evaluating response to ADT. CLINICAL IMPACT. Given the FDA approval and widespread availability of 18F-fluciclovine, the findings could have an impact in the immediate future in guiding initial management of patients with prostate cancer. TRIAL REGISTRATION. ClinicalTrials.gov NCT03264456.

18Fluorodeoxyglucose-positron emission tomography/computed tomography for differentiation of renal tumors in hereditary kidney cancer syndromes

PURPOSE

To assess differences in FDG-PET/CT uptake among four subtypes of renal tumors: clear cell RCC (ccRCC), papillary type I and II RCC (pRCC), and oncocytoma.

METHODS

This retrospective study investigated 33 patients with 98 hereditary renal tumors. Lesions greater than 1 cm and patients with a timeframe of less than 18 months between preoperative imaging and surgery were considered. FDG-PET/CT images were independently reviewed by two nuclear medicine physicians, blinded to clinical information. Volumetric lesion SUV_mean was measured and used to calculate a target-to-background ratio respective to liver (TBR). The Shrout-Fleiss intra-class correlation coefficient was used to assess reliability between readers. A linear mixed effects model, accounting for within-patient correlations, was used to compare TBR values of primary renal lesions with and without distant metastasis.

RESULTS

The time interval between imaging and surgery for all tumors had a median of 77 (Mean: 139; Range: 1-512) days. Intra-class reliability of mean TBR resulted in a mean κ score of 0.93, indicating strong agreement between the readers. The mixed model showed a significant difference in mean TBR among the subtypes (p < 0.0001). Pairwise comparison showed significant differences between pRCC type II and ccRCC (p < 0.0001), pRCC type II and pRCC type I (p = 0.0001), and pRCC type II and oncocytoma (p = 0.0016). Furthermore, a significant difference in FDG uptake was present between primary pRCC type II renal lesions with and without distant metastasis (p = 0.023).

CONCLUSION

pRCC type II lesions demonstrated significantly higher FDG activity than ccRCC, pRCC type I, or oncocytoma. These findings indicate that FDG may prove useful in studying the metabolic activity of renal neoplasms, identifying lesions of highest clinical concern, and ultimately optimizing active surveillance, and personalizing management plans.

Clinical value of 18FDG PET/MRI in muscle-invasive, locally advanced, and metastatic bladder cancer

OBJECTIVE

Metastatic bladder cancer is an aggressive disease that can often be difficult to diagnose and stage with conventional cross-sectional imaging. The primary objective of this study was to determine the clinical value of fluorine-18 2-fluoro-2-deoxy-D-glucose (¹⁸F-FDG) PET/MRI for surveillance and restaging of patients with muscle-invasive, locally advanced, and metastatic bladder cancer compared to conventional imaging methods.

MATERIALS AND METHODS

This retrospective study enrolled patients with muscle-invasive, locally advanced and metastatic bladder cancer in a single institute evaluated with ¹⁸F-FDG PET/MRI. All patients also underwent conventional imaging with CT. Additional imaging may also have included ¹⁸F-FDG PET/CT (¹⁸F-FDG PET), or sodium fluoride (NaF) PET/CT in some patients. Images were reviewed by a diagnostic radiologist/nuclear medicine physician. Number of lesions and sites of disease were captured and compared between ¹⁸F-FDG PET/MRI and conventional imaging. Lesions were confirmed by sequential imaging or lesion biopsy. All patients were followed for survival.

RESULTS

Fifteen patients (4 for surveillance; 11 for restaging) underwent 34 ¹⁸F-FDG PET/MRI scans. Each patient received a corresponding conventional CT around the time of the ¹⁸F-FDG PET/MRI (median 6 days). The 15 patients (11 male; 4 female) had a median age of 61.5 years (range 37-73) and histologies of urothelial carcinoma (n = 13) and small-cell carcinoma of the bladder (n = 2) diagnosed as stage 4 (n = 13), stage 3 (n = 1), or stage 2 (n = 1). ¹⁸F-FDG PET/MRI detected 82 metastatic malignant lesions involving lymph nodes (n = 22), liver (n = 10), lung (n = 34), soft tissue (n = 12), adrenal glands (n = 1), prostate (n = 1), and bone (n = 2) with a resultant advantage of 36% for lesion visibility in comparison with CT. Serial imaging or biopsy confirmed these lesions as malignant.

CONCLUSION

¹⁸F-FDG PET/MRI can detect metastatic lesions which cannot be identified on conventional CT, and this can allow for better treatment planning and improved disease monitoring during therapy.

Efficacy and Safety of the 64Cu(II)Cl2 PET/CT for Urological Malignancies: Phase IIa Clinical Study

PURPOSE OF THE REPORT

The aim of this study was to evaluate safety and efficacy of copper-64(II)dichloride (64Cu(II)Cl2) as a new PET tracer for urological malignancies (UMs).

METHODS

Patients with UM were enrolled in a prospective study. All patients were staged with preoperative CT and 64Cu(II)Cl2 PET/CT. Patient characteristics, anatomical and functional imaging, and final histopathology were recorded. Surgical specimens for histopathological examination were collected. To determine time-activity curves for 64Cu(II)Cl2 uptake in UM and normal tissues, SUVs were calculated. The safety of 64Cu(II)Cl2 was assessed.

RESULTS

Twenty-three patients were included. An administered activity of 174.7 MBq (4.72 mCi) for 64Cu(II)Cl2 was equal to 9.80 mSv of the effective dose. The median SUVmax values were 5.7, 0.9, 1.8, and 9.8 for the prostate, bladder, penis, and kidney, respectively. Median SUVmax values were higher in organs with a malignancy in comparison with healthy tissue (prostate [11.5 vs 5.3, P < 0.001], bladder [6.2 vs 0.9, P = 0.007], and penis [3.9 vs 1.3, P = 0.027]), but not in the kidneys (5.0 vs 10.4, P = 0.998). The highest area under the curve (AUC) was reported for prostate cancer (AUC, 0.978), and the lowest for penile cancer (AUC, 0.775). The detection rates based on the best suggested cutoff according to the SUVmax were 85.7% (6/7) for prostate and bladder and 83.3% (5/6) for penile cancer. Neither drug-related effects nor physiologic responses occurred, nor adverse reactions.

CONCLUSIONS

64Cu(II)Cl2 is an effective and well-tolerated tracer in patients with UM. Our results show higher SUVmax in cancer patients than in healthy subjects. Our findings suggest that 64Cu(II)Cl2 PET/CT is useful in patients affected by prostate, bladder, and penis cancer.

Rs-10889677 variant in interleukin-23 receptor may contribute to creating an inflammatory milieu more susceptible to bladder tumourigenesis: report and meta-analysis

Bladder cancer (BLC) is a recurrent high-risk malignancy typified by an inherent localised chronic inflammation. IL-23-receptor (IL-23R), as a positive regulator in the priming of T helper-17 cells, is regarded a principal coordinator of inflammation-propelled neoplasia. In this article, we indented firstly to scrutinise the influence of rs10889677"A/C" SNP located in IL-23R-gene on BLC development and progression among Egyptians. Findings revealed that the rs10889677"C" allele was significantly associated with the increased BLC risk and its higher frequencies were plainly noticeable in high-grade and invasive tumours when applied the dominant/homozygous/allelic genetic models. Under the same genetic models, elevated serum levels of IL-23R protein in BLC patients were pertinently correlated with the rs10889677"A/C" polymorphism. As a corollary, the frequent up-regulation of IL-23R exerts a subsequent activation of the IL-23/17 inflammatory axis. That is experienced as a drastic increase in IL-23 and IL17 levels under the dominant/homozygous/heterozygous/recessive models. Second, study further described how the rs10889677 variant confers its pro-tumoural influences on IL-23R-bearing immune cells, involving tumour-associated macrophages (TAMs), natural killers (NKs) and CD4⁺ T-helper cells. When the dominant model was adopted, it was observed that patients bearing the rs10889677 "C" allele had lower counts of IL-23R-positive CD56⁺NKs and CD4⁺ T-cells, in tandem with higher levels of IL-23R-positive CD14⁺ TAMs compared with those with rs10889677 "A" allele. To entrench the idea, we did a meta-analysis on BLC patients from three different ethnicities (Asian, Caucasians and African). We observed that rs10889677"SNP" is significantly correlated with increased risk of BLCs in the overall population using over-dominant model. Consequently, authors suggested that the rs10889677 variant could be directly implicated in developing inflammatory environment more prone to generating malignancy.

Polytetrafluoroethylene-like Nanoparticles as a Promising Contrast Agent for Dual Modal Ultrasound and X-ray Bioimaging

Various noninvasive imaging techniques are used to produce deep-tissue and high-resolution images for biomedical research and clinical purposes. Organic and inorganic bioimaging agents have been developed to enhance the resolution and contrast intensity. This paper describes the synthesis of polytetrafluoroethylene-like nanoparticles (PTFE≈ NPs), their characterization, biological activity, and bioimaging properties. Transmission electron microscopy (TEM) images showed the shape and the size of the as-obtained small and ultrasmall PTFE≈ NPs. Fourier transform infrared spectroscopy (FTIR) confirmed the PTFE-like character of the samples. X-ray diffraction (XRD) enabled the determination of the crystallization system, cell lattice, and index of crystallinity of the material in addition to the presence of titania (TiO₂) as the contamination. These findings were corroborated by X-ray photoelectron spectroscopy (XPS) that identifies the chemical states of the elements present in the samples along with their atomic percentages allowing the determination of both the purity index of the sample and the nature of the impurities. Additionally, diffuse reflectance ultraviolet-visible spectroscopy (UV-vis) was used to further assess the optical properties of the materials. Importantly, PTFE≈ NPs showed significant in vitro and in vivo biocompatibility. Lastly, PTFE≈ NPs were tested for their ultrasound and X-ray contrast properties. Our encouraging preliminary results open new avenues for PTFE-like nanomaterials as a suitable multifunctional contrast agent for biomedical imaging applications. Combined with suitable surface chemistry and morphology design, these findings shed light to new opportunities offered by PTFE nanoparticles in the ever-booming biomedical field.

Updated Trends in Cancer in Japan: Incidence in 1985-2015 and Mortality in 1958-2018-A Sign of Decrease in Cancer Incidence

Background

Unlike many North American and European countries, Japan has observed a continuous increase in cancer incidence over the last few decades. We examined the most recent trends in population-based cancer incidence and mortality in Japan.

Methods

National cancer mortality data between 1958 and 2018 were obtained from published vital statistics. Cancer incidence data between 1985 and 2015 were obtained from high-quality population-based cancer registries maintained by three prefectures (Yamagata, Fukui, and Nagasaki). Trends in age-standardized rates (ASR) were examined using Joinpoint regression analysis.

Results

For males, all-cancer incidence increased between 1985 and 1996 (annual percent change [APC] +1.1%; 95% confidence interval [CI], 0.7–1.5%), increased again in 2000–2010 (+1.3%; 95% CI, 0.9–1.8%), and then decreased until 2015 (−1.4%; 95% CI, −2.5 to −0.3%). For females, all-cancer incidence increased until 2010 (+0.8%; 95% CI, 0.6–0.9% in 1985–2004 and +2.4%; 95% CI, 1.3–3.4% in 2004–2010), and stabilized thereafter until 2015. The post-2000 increase was mainly attributable to prostate in males and breast in females, which slowed or levelled during the first decade of the 2000s. After a sustained increase, all-cancer mortality for males decreased in 1996–2013 (−1.6%; 95% CI, −1.6 to −1.5%) and accelerated thereafter until 2018 (−2.5%; 95% CI, −2.9 to −2.0%). All-cancer mortality for females decreased intermittently throughout the observation period, with the most recent APC of −1.0% (95% CI, −1.1 to −0.9%) in 2003–2018. The recent decreases in mortality in both sexes, and in incidence in males, were mainly attributable to stomach, liver, and male lung cancers.

Conclusion

The ASR of all-cancer incidence began decreasing significantly in males and levelled off in females in 2010.

Enhanced Detection of Genitourinary Cancers Using Fragmentation and Copy Number Profiles Obtained from Urinary Cell-Free DNA

BACKGROUND

Recent studies have reported that examining the fragmentation profiles (FP) of plasma cell-free DNA (cfDNA) further improves the clinical sensitivity of tumor detection. We hypothesized that considering the differences of the FP of urinary cfDNA would increase the clinical sensitivity of genitourinary (GU) cancer detection.

METHODS

177 patients with GU cancer and 94 individuals without tumors were enrolled in the discovery cohort. An independent validation dataset comprising 30 patients without tumors and 66 patients with GU cancer was also collected. We constructed an ensemble classifier, GUIDER, to detect and localize GU cancers using fragmentation and copy number profiles obtained from shallow whole-genome sequencing of urinary cfDNA.

RESULTS

Urinary cfDNA of patients with GU cancer had a higher proportion of long fragments (209-280 bp) and a lower proportion of short fragments (140-208 bp) compared to controls. The overall mean classification accuracy of the FP was 74.62%-85.39% for different algorithms, and integration of the FP and copy number alteration (CNA) features further enhanced the classification of samples from patients with GU cancer. The mean diagnostic accuracy was further improved by the ensemble classifier GUIDER, which integrated the FP and CNA profiles and resulted in a higher mean accuracy (87.52%) compared to the analysis performed without FP features (74.62%). GUIDER performed well in an independent validation dataset.

CONCLUSIONS

The lengthening and shortening of urinary cfDNA within specific size ranges were identified in patients with GU cancer. Integration of the FP should further enhance the ability to use urinary cfDNA as a molecular diagnostic tool.

Systematic imaging in medicine: a comprehensive review

Systematic imaging can be broadly defined as the systematic identification and characterization of biological processes at multiple scales and levels. In contrast to "classical" diagnostic imaging, systematic imaging emphasizes on detecting the overall abnormalities including molecular, functional, and structural alterations occurring during disease course in a systematic manner, rather than just one aspect in a partial manner. Concomitant efforts including improvement of imaging instruments, development of novel imaging agents, and advancement of artificial intelligence are warranted for achievement of systematic imaging. It is undeniable that scientists and radiologists will play a predominant role in directing this burgeoning field. This article introduces several recent developments in imaging modalities and nanoparticles-based imaging agents, and discusses how systematic imaging can be achieved. In the near future, systematic imaging which combines multiple imaging modalities with multimodal imaging agents will pave a new avenue for comprehensive characterization of diseases, successful achievement of image-guided therapy, precise evaluation of therapeutic effects, and rapid development of novel pharmaceuticals, with the final goal of improving human health-related outcomes.

A review of current advancements and limitations of artificial intelligence in genitourinary cancers

Advances in deep learning and neural networking have allowed clinicians to understand the impact that artificial intelligence (AI) could have on improving clinical outcomes and resources expenditures. In the realm of genitourinary (GU) cancers, AI has had particular success in improving the diagnosis and treatment of prostate, renal, and bladder cancers. Numerous studies have developed methods to utilize neural networks to automate prognosis prediction, treatment plan optimization, and patient education. Furthermore, many groups have explored other techniques, including digital pathology and expert 3D modeling systems. Compared to established methods, nearly all the studies showed some level of improvement and there is evidence that AI pipelines can reduce the subjectivity in the diagnosis and management of GU malignancies. However, despite the many potential benefits of utilizing AI in urologic oncology, there are some notable limitations of AI when combating real-world data sets. Thus, it is vital that more prospective studies be conducted that will allow for a better understanding of the benefits of AI to both cancer patients and urologists.

The Movember Prostate Cancer Landscape Analysis: an assessment of unmet research needs

Prostate cancer is a heterogeneous cancer with widely varying levels of morbidity and mortality. Approaches to prostate cancer screening, diagnosis, surveillance, treatment and management differ around the world. To identify the highest priority research needs across the prostate cancer biomedical research domain, Movember conducted a landscape analysis with the aim of maximizing the effect of future research investment through global collaborative efforts and partnerships. A global Landscape Analysis Committee (LAC) was established to act as an independent group of experts across urology, medical oncology, radiation oncology, radiology, pathology, translational research, health economics and patient advocacy. Men with prostate cancer and thought leaders from a variety of disciplines provided a range of key insights through a range of interviews. Insights were prioritized against predetermined criteria to understand the areas of greatest unmet need. From these efforts, 17 research needs in prostate cancer were agreed on and prioritized, and 3 received the maximum prioritization score by the LAC: first, to establish more sensitive and specific tests to improve disease screening and diagnosis; second, to develop indicators to better stratify low-risk prostate cancer for determining which men should go on active surveillance; and third, to integrate companion diagnostics into randomized clinical trials to enable prediction of treatment response. On the basis of the findings from the landscape analysis, Movember will now have an increased focus on addressing the specific research needs that have been identified, with particular investment in research efforts that reduce disease progression and lead to improved therapies for advanced prostate cancer.

The Movember global Landscape Analysis Committee (LAC) was established to act as an independent group of experts across urology, medical oncology, radiation oncology, radiology, pathology, translational research, health economics and patient advocacy to identify the highest priority research needs across the prostate cancer biomedical research domain. Findings from the landscape analysis illustrate the research priorities in prostate cancer and will enable Movember to focus on specific needs, with particular investment in research to reduce disease progression and improve therapies for advanced prostate cancer.

Effect of neoadjuvant chemotherapy in patients undergoing radical cystectomy for muscle-invasive bladder cancer: a retrospective, multi-institutional study

OBJECTIVE

We evaluated the effect of neoadjuvant chemotherapy in patients undergoing radical cystectomy for urothelial bladder cancer.

METHODS

We retrospectively examined 140 consecutive patients with muscle-invasive bladder cancer (clinical stage T2 to T4 and N0) who underwent radical cystectomy with or without neoadjuvant chemotherapy at four academic institutions between January 2006 and December 2016. Patients were categorized into the neoadjuvant chemotherapy group (those who underwent treatment with any neoadjuvant chemotherapy regimen; n = 69) and the non-neoadjuvant chemotherapy group (those who did not receive any neoadjuvant chemotherapy regimen; n = 71). The primary outcome measure was overall survival.

RESULTS

The 5-year overall survival rates were 58.0% and 61.8% in the neoadjuvant chemotherapy and non-neoadjuvant chemotherapy groups, respectively (P = 0.320). The 5-year overall survival rates for the neoadjuvant chemotherapy and non-neoadjuvant chemotherapy groups were 64.8% and 68.4%, respectively, among cT2N0 patients (P = 0.688) and 38.6% and 21.6%, respectively, among cT3-4aN0 patients (P = 0.290). When patients with cT3-4aN0 disease in the neoadjuvant chemotherapy group were divided into responders (<pT2) and non-responders (pT2-pT4), responders (<pT2) to neoadjuvant chemotherapy had a better 5-year overall survival rate (83.6%) than non-responders (pT2-pT4; 23.1%; P < 0.05); this was also observed in the non-neoadjuvant chemotherapy group (21.6%; P < 0.05). On multivariate analysis, the pathological T stage (<pT2 vs. ≥pT2) was a significant predictor of overall survival in the neoadjuvant chemotherapy group.

CONCLUSION

Among cT3-4aN0 patients, survival outcomes were significantly better in responders (<pT2) to neoadjuvant chemotherapy than in non-responders (≥pT2) and in patients in the non-neoadjuvant chemotherapy group. Among patients with advanced stage disease (cT3 or 4), responders (<pT2) to neoadjuvant chemotherapy had a significant survival benefit.

EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer-An International Collaborative Multistakeholder Effort†: Under the Auspices of the EAU-ESMO Guidelines Committees

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts prior to voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), and 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these statements, 33 (28%) achieved level 1 consensus and 49 (42%) achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease, and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time when further evidence is available to guide our approach.

PATIENT SUMMARY

This report summarises findings from an international, multistakeholder project organised by the EAU and ESMO. In this project, a steering committee identified areas of bladder cancer management where there is currently no good-quality evidence to guide treatment decisions. From this, they developed a series of proposed statements, 71 of which achieved consensus by a large group of experts in the field of bladder cancer. It is anticipated that these statements will provide further guidance to health care professionals and could help improve patient outcomes until a time when good-quality evidence is available.

Application of Radiomics for Personalized Treatment of Cancer Patients

Radiomics is a novel concept that relies on obtaining image data from examinations such as computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET). With the appropriate algorithm, the extracted results have broad applicability and potential for a massive positive impact in radiology. For example, clinicians can verify treatment efficiency, predict the location of tumor metastasis, correlate results with a histopathological examination, or more accurately define the type of cancer. Combining radiomics with other testing techniques allows every patient to have a personalized treatment plan that is essential for advanced examination and treatment. This article explains the process of radiomics, including data collection mechanisms, combined use with genomics, and artificial intelligence and immunology techniques, which may solve many of the challenges faced by doctors in diagnosing and treating their patients.

Preoperative imaging for locoregional staging of bladder cancer

Bladder cancer is the ninth most common cancer, expected to lead to an estimated 17,670 deaths in the United States in 2019. Clinical management and prognosis of bladder cancer mainly depend on the extent of locoregional disease, particularly whether bladder muscle is involved. Therefore, bladder cancer is often divided into superficial, non-muscle-invasive bladder cancer and muscle-invasive bladder cancer; the latter often prompts consideration for cystectomy. While precise staging prior to cystectomy is crucial, the optimal preoperative imaging modality used to stage the disease remains controversial. Transurethral resection of bladder tumor (TURBT) followed by computed tomography (CT) urography is the current recommended approach for staging bladder cancer but suffers from a high rate of understaging. We review the recent literature and compare different imaging modalities for assessing the presence of muscle invasion and lymph node involvement prior to cystectomy and highlight the advantages of each modality.

The long-term rapid increase in incidence of adenocarcinoma of the kidney in the USA, especially among younger ages

BACKGROUND

We previously observed a rapid increase in the incidence of renal cell carcinoma (RCC) in men and women between 1935 and 1989 in the USA, using data from the Connecticut Tumor Registry. This increase appeared to be largely explained by a positive cohort effect, but no population-based study has been conducted to comprehensively examine age-period-cohort effects by histologic types for the past decade.

METHODS

We calculated age-adjusted and age-specific incidence rates of the two major kidney-cancer subtypes RCC and renal urothelial carcinoma, and conducted an age-period-cohort analysis of 114 138 incident cases of kidney cancer reported between 1992 and 2014 to the Surveillance, Epidemiology, and End Results programme.

RESULTS

The age-adjusted incidence rates of RCC have been increasing consistently in the USA among both men and women (from 12.18/100 000 in 1992-1994 to 18.35/100 000 in 2010-2014 among men; from 5.77/100 000 in 1992-1994 to 8.63/100 000 in 2010-2014 among women). Incidence rates generally increased in successive birth cohorts, with a continuing increase in rates among the younger age groups (ages 0-54 years) in both men and women and among both Whites and Blacks. These observations were confirmed by age-period-cohort modelling, which suggested an increasing birth-cohort trend for RCC beginning with 1955 birth cohorts, regardless of the assumed value for the period effect for both men and women and for Whites and Blacks.

CONCLUSIONS

Known risk factors for kidney cancer may not fully account for the observed increasing rates or the birth-cohort pattern for RCC, prompting the need for additional etiologic hypotheses (such as environmental exposures) to investigate these descriptive patterns.

[Influence of immunomodulators on urological imaging]

BACKGROUND

Immune checkpoint inhibitors (ICI) have led to great advances in the therapy of metastatic renal cell and urothelial carcinoma. Currently ICI are approved for the first-line therapy of cisplatin-unfit patients (Atezolizumab, Pembrolizumab) and second-line therapy in patients with metastasized urothelial cancer (Atezolizumab, Nivolumab, Pembrolizumab). For the therapy of metastasized RCC, Nivolumab is approved as a second-line therapy and in combination with the CTLA‑4 antibody Ipilimumab as a first-line therapy.

OBJECTIVES

What does the optimized radiological follow-up and therapy response assessment for ICI, which differ in their pathways from common chemotherapeutics and anti-angiogenetic drugs, look like? What strategies are needed to meet the upcoming challenges concerning interpretation of the acquired images?

METHODS

A systematic literature search was carried out for urothelial and renal cell carcinoma.

RESULTS

Immune-related response criteria have been introduced to better characterize the imaging changes occurring under ICI, as monitoring response to immunotherapy still relies on RECIST.

CONCLUSIONS

To properly identify and predict response after treatment with ICI, additional studies with long-term follow-ups are needed. Because of the growing use of ICI, radiologists and urologist should be familiar with common imaging findings (such as pseudo progress) under immunotherapy to correctly interpret these findings in daily routine.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

Imaging of Unusual Renal Tumors

PURPOSE OF REVIEW

Renal masses are a wide entity and a common finding in clinical practice. Detection of these masses has increased in the last years, yet mortality rates have slightly decreased.

RECENT FINDINGS

According to the World Health Organization classification, there are 8 types, 51 subtypes, and a lot more subsequent subclassifications of renal tumors. Histopathological analysis should always be assessed for final diagnosis of theses tumors. However, imaging can be an important diagnostic guidance. The most common diagnoses of renal tumor are clear cell carcinoma, papillary renal cell carcinoma, angiomyolipoma, and transitional cell carcinoma. Nonetheless, a considerable variety of particular tumors can arise from the kidney, challenging the expertise of radiologists and urologists on this subject. The awareness of these unusual entities is vital for professionals working at a complex medical facility with greater volume of patients. We hereby present uncommon renal tumors and its pathological and radiological features.

Neoadjuvant chemotherapy with gemcitabine and cisplatin for muscle-invasive bladder cancer: multicenter retrospective study

Objectives

The aim of this study was to evaluate the efficacy of neoadjuvant gemcitabine and cisplatin (GC) therapy for muscle-invasive bladder cancer (MIBC).

Methods

We retrospectively evaluated patients who underwent neoadjuvant GC therapy followed by radical cystectomy from April 2009 through December 2015 in the Sapporo Medical University Urologic Consortium. The efficacy of neoadjuvant chemotherapy (NAC) was assessed based on the pathological T0 (pT0) rate in radical cystectomy specimens, and the recurrence-free survival, cause-specific survival and overall survival (OS) rates. To compare the oncological benefit of NC with GC to that of the methotrexate, vinblastine, adriamycin and cisplatin (MVAC) regimen, we also utilized historical clinical data of patients who were treated with MVAC as NAC followed by radical cystectomy in our institute from 1986 through 2010.

Results

Fifty-eight patients receiving neoadjuvant GC therapy and 74 receiving neoadjuvant MVAC were included. The pT0 achieving rates were comparable between the two groups (20.7% vs. 18.9%, P = 0.83). Neoadjuvant GC was associated with a better 2-year OS rate than neoadjuvant MVAC for clinical T2 disease (95.2% vs. 70.8%, P = 0.036). In contrast, in patients with clinical T3 or more advanced disease, neoadjuvant MVAC provided more pT0 (20.0% vs. 5.6%, P = 0.07) and better 2-year OS than neoadjuvant GC (71.1% vs. 55.0%, P = 0.142), although the difference did not reach statistical significance.

Conclusions

Neoadjuvant GC had no inferiority in oncological outcomes to MVAC for MIBC.

Evaluation of lymph node status in patients with urothelial carcinoma-still in search of the perfect imaging modality: a systematic review

While accurate lymph node status evaluation in urothelial carcinoma patients is essential for the correct disease staging and, hence, establishing the most beneficial treatment strategy, the diagnostic performance of routine imaging in regards to this issue is not satisfactory. For the purpose of this article, we systematically reviewed the contemporary literature on the sensitivity and specificity of particular imaging modalities which have been studied for detecting lymph node metastases in patients diagnosed with urothelial carcinoma. The evidence reviewed shows that computed tomography (CT), although recognized as the imaging modality of choice, is associated with marked limitations, resulting in its low sensitivity for lymph node involvement detection in urothelial carcinoma patients, with no study reporting a value higher than 46% using standard cut-off values. Markedly higher sensitivity rates may be achieved with magnetic resonance imaging (MRI), especially when using ultrasmall superparamagnetic iron oxide as the contrast agent, however, no uniform protocol has been systematically studied up to date. The vast majority of recent evidence concerns positron emission tomography (PET), which is being reported to improve the diagnostic performance of CT alone, as has been demonstrated in multiple articles, which investigated the accuracy of PET/CT at primary or post-treatment staging of urothelial carcinoma patients. However, there has been substantial heterogeneity in terms of methodology and results between those studies, making it premature to draw any definitive conclusions. The results of this review lead to a conclusion, that while CT, despite being not fully satisfactory, still remains the gold-standard method of imaging for staging purposes in urothelial carcinoma, other imaging modalities are under investigation, with promising results.

Imaging response assessment of immunotherapy in patients with renal cell and urothelial carcinoma

PURPOSE OF REVIEW

Recent advances in anticancer immunotherapy have revolutionized the treatment of metastatic renal cell (RCC) and urothelial carcinoma. In this review, we discuss the mechanisms of action of these new therapeutic approaches, explicate the common adverse events, and highlight different imaging-based response criteria.

RECENT FINDINGS

The recent introduction of immune-checkpoint inhibitors led to substantial advances in therapy of metastatic RCC and urothelial carcinoma. Because of the distinct effector mechanisms of these new substances, atypical response patterns such as transient enlargements of tumor lesions, appearance of new lesions after therapy, no measurable decrease in tumor size, or delayed responses are observed in medical imaging studies. This indicates that the established imaging-based response assessment according to the Response Evaluation Criteria in Solid Tumors (RECIST) guidelines has shortcomings to comprehensively evaluate treatment effects.

SUMMARY

While monitoring response to immunotherapy still relies on RECIST criteria, immune-related response criteria have been established to better address the imaging changes occurring under immunotherapy. Further studies with long-term follow-up are needed to properly identify and predict response after treatment beyond progression. Because of the expanding clinical use of immune checkpoint inhibitors, radiologists, urologist, and oncologists should be familiar with common imaging findings under this respective therapy.

Challenges and advances in the diagnosis, biology, and treatment of urothelial upper tract and bladder carcinomas

Urothelial carcinomas span the bladder, ureter, and renal pelvis, and while there had been stagnation in the field of drug approval for the past two decades, there is now accelerated and regular US FDA approval of 5 immunotherapy agents. However, patients who inherently do not respond or progress on such therapies still represent an area of increased unmet need. In this special Seminars issue, we explore varying aspects of bladder urothelial carcinoma treatment with targeted therapies, the unique presentation and challenges in the treatment of upper tract and renal pelvis tumors, as well as new and emerging diagnostic imaging tools for varying genitourinary cancers.

Pretreatment 3T multiparametric MRI staging predicts for biochemical failure in high-risk prostate cancer treated with combination high-dose-rate brachytherapy and external beam radiotherapy

PURPOSE

To determine whether pretreatment 3T multiparametric MRI (mpMRI) staging impacts biochemical recurrence-free survival (BRFS) or distant metastasis-free survival (DMFS) for men with high-risk prostate cancer treated with combination high-dose-rate (HDR) brachytherapy and external beam radiation therapy (EBRT).

MATERIALS AND METHODS

This institutional review board-approved retrospective study included a cohort of 37 men with high-risk prostate cancer treated with HDR brachytherapy and EBRT after 3T mpMRI. Kaplan-Meier analysis was used to evaluate whether mpMRI evidence of extracapsular extension or seminal vesicle invasion (SVI) resulted in differences in BRFS or DMFS. Pretreatment and treatment-related variables were evaluated for association with biochemical failure (Phoenix definition) and distant metastatic failure using univariate Cox regression analysis.

RESULTS

The median prostate-specific antigen at diagnosis was 9 ng/mL (range 2-100). Biopsy Gleason score (bGS) was ≤8 in 38% and nine in 62%. Clinical T-category was T1-T2 in 89%, T3a in 8%, and T3b in 3%. With a median followup of 30.6 months, actuarial 3-year BRFS and DMFS were 76% and 86%, respectively. Kaplan-Meier analysis revealed that mpMRI evidence of extracapsular extension or SVI resulted in significantly higher rates of both biochemical recurrence and distant failure. Using Cox regression analysis, only mpMRI evidence of SVI vs. no SVI predicted for biochemical failure (hazard ratio 13.98, p = 0.0055).

CONCLUSIONS

For high-risk prostate cancer treated with combination HDR brachytherapy and EBRT, mpMRI evidence of SVI predicted for biochemical failure, whereas traditional pretreatment variables did not. Therefore, pretreatment 3T mpMRI appears useful for identifying men who may benefit from treatment intensification.