Can MRI Help Inform Which Men With a History of Multifocal High-Grade Prostatic Intraepithelial Neoplasia or Atypical Small Acinar Proliferation Remain at an Elevated Risk for Clinically Significant Prostate Cancer?

PURPOSE

We investigated the association of MRI findings in men with a previous diagnosis of atypical small acinar proliferation (ASAP) or multifocal high-grade intraepithelial neoplasia (HGPIN) with pathologic findings on repeat biopsy.

MATERIALS AND METHODS

We retrospectively reviewed patients with ASAP/multifocal HGPIN undergoing a repeat biopsy in the Michigan Urological Surgery Improvement Collaborative registry. We included men with and without an MRI after the index biopsy demonstrating ASAP/multifocal HGPIN but before the repeat biopsy. Men with an MRI prior to the index biopsy were excluded. We compared the proportion of men with ≥ GG2 CaP (Grade Group 2 prostate cancer) on repeat biopsy among the following groups with the χ2 test: no MRI, PIRADS (Prostate Imaging-Reporting and Data System) ≥ 4, and PIRADS ≤ 3. Multivariable models were used to estimate the adjusted association between MRI findings and ≥ GG2 CaP on repeat biopsy.

RESULTS

Among the 207 men with a previous diagnosis of ASAP/multifocal HGPIN that underwent a repeat biopsy, men with a PIRADS ≥ 4 lesion had a higher proportion of ≥ GG2 CaP (56%) compared with men without an MRI (12%, P < .001). A lower proportion of men with PIRADS ≤ 3 lesions had ≥ GG2 CaP (3.0%) compared with men without an MRI (12%, P = .13). In the adjusted model, men with a PIRADS 4 to 5 lesion had higher odds (OR: 11.4, P < .001) of ≥ GG2 CaP on repeat biopsy.

CONCLUSIONS

MRI is a valuable diagnostic tool to triage which men with a history of ASAP or multifocal HGPIN on initial biopsy should undergo or avoid repeat biopsy without missing clinically significant CaP.

Prostate cancer detection and segmentation on MRI using non-local mask R-CNN with histopathological ground truth

BACKGROUND

Automatic detection and segmentation of intraprostatic lesions (ILs) on preoperative multiparametric-magnetic resonance images (mp-MRI) can improve clinical workflow efficiency and enhance the diagnostic accuracy of prostate cancer and is an essential step in dominant intraprostatic lesion boost.

PURPOSE

The goal is to improve the detection and segmentation accuracy of 3D ILs in MRI by a proposed a deep learning (DL)-based algorithm with histopathological ground truth.

METHODS

This retrospective study included 262 patients with in vivo prostate biparametric MRI (bp-MRI) scans and were divided into three cohorts based on their data analysis and annotation. Histopathological ground truth was established by using histopathology images as delineation reference standard on cohort 1, which consisted of 64 patients and was randomly split into 20 training, 12 validation, and 32 testing patients. Cohort 2 consisted of 158 patients with bp-MRI based lesion delineation, and was randomly split into 104 training, 15 validation, and 39 testing patients. Cohort 3 consisted of 40 unannotated patients, used in semi-supervised learning. We proposed a non-local Mask R-CNN and boosted its performance by applying different training techniques. The performance of non-local Mask R-CNN was compared with baseline Mask R-CNN, 3D U-Net and an experienced radiologist's delineation and was evaluated by detection rate, dice similarity coefficient (DSC), sensitivity, and Hausdorff Distance (HD).

RESULTS

The independent testing set consists of 32 patients with histopathological ground truth. With the training technique maximizing detection rate, the non-local Mask R-CNN achieved 80.5% and 94.7% detection rate; 0.548 and 0.604 DSC; 5.72 and 6.36 95 HD (mm); 0.613 and 0.580 sensitivity for ILs of all Gleason Grade groups (GGGs) and clinically significant ILs (GGG > 2), which outperformed baseline Mask R-CNN and 3D U-Net. For clinically significant ILs, the model segmentation accuracy was significantly higher than that of the experienced radiologist involved in the study, who achieved 0.512 DSC (p = 0.04), 8.21 (p = 0.041) 95 HD (mm), and 0.398 (p = 0.001) sensitivity.

CONCLUSION

The proposed DL model achieved state-of-art performance and has the potential to help improve radiotherapy treatment planning and noninvasive prostate cancer diagnosis.

Adipocytic Differentiation in a Sertoli Cell Tumor

Testicular sex cord-stromal tumors are clonal neoplasms, with the majority being of Leydig cell followed by Sertoli cell origins. In Leydig cell tumors, adipocytic differentiation has been previously reported as a possible distinguishing feature, which has not been reported in other sex cord-stromal tumors. Herein, we report a case of a 48-year-old man who presented with an incidentally discovered 1.1 cm testicular mass, for which he underwent partial orchiectomy. Microscopically, the tumor showed features consistent with sex cord-stromal tumor with strong and diffuse nuclear and cytoplasmic reaction for B-catenin immunohistochemistry, supporting the diagnosis of Sertoli cell tumor. A novel adipocytic differentiation, reported previously in Leydig cell tumors, was present in this tumor.

Diagnosis and management of testicular compartment syndrome caused by tension hydrocele

A hydrocele is an abnormal collection of fluid within the tunica vaginalis which may either be congenital or acquired. Hydroceles are usually painless and don't require immediate intervention unless they impact activities of daily living. This case demonstrates a rare complication of hydroceles termed tension hydrocele which presented with scrotal swelling and acute pain. Unlike the classic presentation of hydroceles with minimal pain or discomfort, it is important to recognize tension hydroceles as an extremely rare but possible cause of acute scrotum, which needs to be emergently diagnosed and treated.

Utilizing lesion diameter and prostate specific antigen density to decide on magnetic resonance imaging guided confirmatory biopsy of prostate imaging reporting and data system score three lesions in African American prostate cancer patients managed with active surveillance

OBJECTIVE

The objective of the study is to identify the rate of significant prostate cancer (PCa) detection in PI-RADS3 lesions in AA patients stratified by PSAD threshold of < 0.15 vs. ≥ 0.15 ng/ml² and lesion diameter of < 1 cm vs ≥ 1 cm.

METHODS

We analyzed our institutional database of MRI-TB to identify the rate of significant prostate cancer (PCa) detection in PI-RADS3 lesions in AA patients stratified by PSAD threshold of < 0.15 vs. ≥ 0.15 ng/ml² and lesion diameter of < 1 cm vs ≥ 1 cm. Significant prostate cancer was defined as Gleason grade group 2 or higher on MRI-TB of the PI-RADS 3 lesion.

RESULTS

Of 768 patients included in the database, 211 (27.5%) patients identified themselves as AAs. Mean age of AA patients was 63 years and mean PSAD was 0.21. Sixty nine (32.7%) AA patients were found to have PI-RADS 3 lesions. Mean PSAD of AA patients with PI-RADS 3 lesions was 0.21 ng/ml² as well. Fifty percent of AA patients with PI-RADS 3 lesions had PSAD ≥ 0.15 ng/ml². Significant PCa detection rate for AA patients with PI-RADS 3 lesions was 9% for PSAD of ≥ 0.15 vs. 0.03% percent for AA patients with PSAD < 0.15 ng/ml² (OR 7.056, CI 1.017-167.9, P = 0.04). Stratification by lesion diameter (< 1 cm vs. > 1 cm) resulted in missing 0% of significant PCa when only AA patients with PSAD ≥ 0.15 ng/ml² and lesion diameter ≥ 1 cm received MRI-TB.

CONCLUSIONS

We report on the performance of a reported PSAD density threshold in detecting significant PCa in one of the largest series of AA patients receiving MRI-TB of the prostate. Our results have direct clinical implications when counseling AA patients with PI-RADS 3 lesion on whether they should undergo MRI-TB of such lesions.

Abstract 186: Gleason grade group predictions from mp-MRI of prostate cancer patients using auto deep learning

Gleason Grade Group Predictions from mp-MRI of Prostate Cancer Patients using Automated Deep Learning

Though histopathology remains the gold standard, there have been significant interests in predicting Gleason Grade using noninvasive imaging such as mp-MRI. Most studies simplify the task into binary classification for the high uncertainty at each group. Handcrafted radiomic features were heavily investigated but prone to errors from the definition of region of interest, feature extraction variations, etc. We proposed an automated deep learning framework (auto-Keras) to predict the group directly based on the 3D data of the whole prostate gland. The training cohort A consisted of 96 PCa patients from SPIE-AAPM-NCI Challenge. The number of patients in each Group was 30, 35, 18, 7, and 6. The testing cohort B consisted of 34 PCa patients from our institute (10, 14, 4, 3, 3). We resampled and rigidly registered ADC and T2WI. N4-bias correction was applied to correct the non-uniformity. For each slice, we performed Gaussian blurring followed by prostate cropping from contour delineated by two clinicians.We tested five scenarios, including input of T2WI, ADC, both, two parallel inputs followed by feature concatenation, and prediction ensemble. The search space of augmentation included translation, flip, rotation, zooming, and contrast. The search space of the architectures had vanilla, ResNet, and Xception. With ADC alone, the model detected 75% of patients in Group 3. Using T2WI and ADC as input, 46% of Group 2 and 40% of Group 1 were identified. Since GG 2 is less aggressive and has a favorable outcome, we further studied the performance of classifying 1 VS. 2-5 and 1-2 VS. 3-5. The models' precision and recall were 91% and 72% for 1-2, 60% and 24% for 3-5. We separated 1 VS. 2-5, with a 96% precision and 73% recall for 2-5. The model had a better performance to predict lower GG when the input contained both T2WI and AD, and better at higher GG when the features were concatenated at the output level.

Table 1.Performance of Precision and recall for Gleason Grade Group on the testing cohort.1 VS. 2 VS. 3 VS. 4 VS. 51-2 VS. 3-51 VS. 2-5ADC-onlyGroup 1Group 2Group 3Group 4Group 5Group 1-2Group 3-5Group 1Group 2-5Precision0.100.230.75000.300.500.300.50Recall0.250.380.14--0.580.240.580.24Input MergePrecision0.400.460.25000.910.200.400.61Recall0.310.380.25--0.720.500.310.70Feature MergePrecision0.200.080.250.3300.130.600.200.96Recall0.670.250.250.0600.430.230.670.73PredictionEnsemblePrecision0.200.080.750.3300.170.600.200.91Recall0.500.250.200.10-0.500.240.500.72

Citation Format: Weiwei Zong, Eric Carver, Aharon Feldman, Joon Lee, Zhen Sun, Lanyu Xu, Ali Dabaja, Ning Wen. Gleason grade group predictions from mp-MRI of prostate cancer patients using auto deep learning [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 186.

Targeting Neuroinflammation in Brain Cancer: Uncovering Mechanisms, Pharmacological Targets, and Neuropharmaceutical Developments

Gliomas are one of the most lethal types of cancers accounting for ∼80% of all central nervous system (CNS) primary malignancies. Among gliomas, glioblastomas (GBM) are the most aggressive, characterized by a median patient survival of fewer than 15  months. Recent molecular characterization studies uncovered the genetic signatures and methylation status of gliomas and correlate these with clinical prognosis. The most relevant molecular characteristics for the new glioma classification are IDH mutation, chromosome 1p/19q deletion, histone mutations, and other genetic parameters such as ATRX loss, TP53, and TERT mutations, as well as DNA methylation levels. Similar to other solid tumors, glioma progression is impacted by the complex interactions between the tumor cells and immune cells within the tumor microenvironment. The immune system’s response to cancer can impact the glioma’s survival, proliferation, and invasiveness. Salient characteristics of gliomas include enhanced vascularization, stimulation of a hypoxic tumor microenvironment, increased oxidative stress, and an immune suppressive milieu. These processes promote the neuro-inflammatory tumor microenvironment which can lead to the loss of blood-brain barrier (BBB) integrity. The consequences of a compromised BBB are deleteriously exposing the brain to potentially harmful concentrations of substances from the peripheral circulation, adversely affecting neuronal signaling, and abnormal immune cell infiltration; all of which can lead to disruption of brain homeostasis. In this review, we first describe the unique features of inflammation in CNS tumors. We then discuss the mechanisms of tumor-initiating neuro-inflammatory microenvironment and its impact on tumor invasion and progression. Finally, we also discuss potential pharmacological interventions that can be used to target neuro-inflammation in gliomas.

462. Prevalence and Outcome of Asymptomatic Procedural Patients with COVID-19 Infection

Background

Guidelines recommend testing for SARS-COV-2 in asymptomatic individuals who are undergoing time-sensitive major surgery or aerosol generating procedures (AGPs) to guide infection prevention practices, including PPE use, and minimize risk of potential poor outcomes associated with COVID-19 infection by delaying the procedure in positive patients. However, evidence to support these recommendations are limited. We describe the outcome of asymptomatic patients with SARS-COV-2 undergoing surgery or AGPs.

Methods

We implemented a system-wide policy to test all patients requiring intubation or other AGPs at Henry Ford Health System (HFHS), a 5-hospital system in southeast Michigan. This was a retrospective review of asymptomatic surgical patients with COVID-19 infection between 5/1/2020–5/31/2020. All patients with positive polymerase chain reaction (PCR) of upper respiratory tract were included. Demographics, comorbidities, procedural/surgical categories, symptoms and outcomes were evaluated.

Results

4381 COVID-19 PCR tests were performed pre-procedurally during the study period, of which 18 (0.4%) were positive. Summary of characteristics is presented in Table 1. Mean age was 49.7 years, and the majority were female (61%) and black (67%). Six (33%) of 18 surgeries were performed despite positive COVID-19 PCR as shown in Table 2. Of those who had the procedure performed, none developed symptoms within 14 days. Two (11%) patients developed symptoms within 14 days of positive PCR after their procedures were canceled. None of those who had their procedure delayed developed any symptoms. Of the total patients, none required hospitalization or died.

Table 1. Characteristics of asymptomatic patients with COVID-19 infection

Table 2. Outcome of procedure in asymptomatic patients with COVID-19

Conclusion

The prevalence of COVID-19 infection was very low in our asymptomatic patient population. Decisions around SARS-CoV-2 testing in asymptomatic patients undergoing procedures should be based on exposure history and prevalence of disease in the community to avoid unnecessary testing and diversion of resources away from symptomatic patients.

Disclosures

All Authors: No reported disclosures

Post Prostatectomy Pathologic Findings of Patients With Clinically Significant Prostate Cancer and no Significant PI-RADS Lesions on Preoperative Magnetic Resonance Imaging

OBJECTIVES

We present postprostatectomy pathology results from a series of prostate cancer (Pca) Gleason grade group ≥2 patients who did not have findings suggestive of cancer on preoperative pelvic magnetic resonance imaging (MRI).

METHODS

We performed an institutional retrospective study of prostate magnetic resonance imaging (MRI) examinations done from October 2015 to February 2018. We identified patients who underwent prostatectomy for Pca Gleason ≥3 + 4 diagnosed on prostate biopsy with no associated MRI findings suggestive of malignancy and analyzed their postprostatectomy pathologic findings and MRI imaging results.

RESULTS

At our institution, 850 men with Pca received MRI between 2015 and 2018, and 156/850 patients received robotic-assisted radical prostatectomy. Thirty-three patients (33/156 = 21%) had negative MRI for PIRAD 3 or greater but had a biopsy showing significant Pca. Their mean (range) age was 62.7 (50-86) years. Their median (interquartile range) PSA, and PSA density were, 4.6 (3.7) ng/mL and 0.12 (0.05) ng/mL/cm², respectively; all not significantly different from patients with visible lesions on MRI who underwent surgery. On post prostatectomy pathology, 27/33 (82%) men had Pca Gleason score 7 or greater. The most common pattern was infiltrative growth with cancer glands intermingling between benign glands.

CONCLUSION

We describe the pathologic and imaging findings in an extensive series of men with clinically significant Pca with no significant lesions on preoperative MRI. Our results support the importance of patient counseling on the risk of missing significant Pca on MRI in isolation from other clinical variables.

Best Approaches to Evaluation and Feedback in Post-Graduate Medical Education

PURPOSE OF REVIEW

The objectives of this literature review are to appraise current approaches and assess new technologies that have been utilized for evaluation and feedback of residents, with focus on surgical trainees.

RECENT FINDINGS

In 1999, the Accreditation Council for Graduate Medical Education introduced the Milestone system as a tool for summative evaluation. The organization allows individual program autonomy on how evaluation and feedback are performed. In the past, questionnaire evaluations and informal verbal feedback were employed. However, with the advent of technology, they have taken a different shape in the form of crowdsourcing, mobile platforms, and simulation. Limited data is available on new methods but studies show promise citing low cost and positive impact on resident education. No one "best approach" exists for evaluation and feedback. However, it is apparent that a multimodal approach that is based on the ACGME Milestones can be effective and aid in guiding programs.

Managing Urology Consultations During COVID-19 Pandemic: Application of a Structured Care Pathway

Objective

To describe and evaluate a risk-stratified triage pathway for inpatient urology consultations during the SARS-CoV-2 (COVID-19) pandemic. This pathway seeks to outline a urology patient care strategy that reduces the transmission risk to both healthcare providers and patients, reduces the healthcare burden, and maintains appropriate patient care.

Materials and Methods

Consultations to the urology service during a 3-week period (March 16 to April 2, 2020) were triaged and managed via one of 3 pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A P value <.05 was considered significant.

Results

Between March 16 and April 2, 2020, 53 inpatient consultations were performed. By following our triage pathway, a total of 19/53 consultations (35.8%) were performed via Telemedicine with no in-person exposure, 10/53 consultations (18.9%) were High-Risk, in which we strictly controlled the urology team member in-person contact, and the remainder, 24/53 consultations (45.2%), were performed as Standard in-person encounters. COVID-19 associated consultations represented 18/53 (34.0%) of all consultations during this period, and of these, 8/18 (44.4%) were managed successfully via Telemedicine alone. No team member developed COVID-19 infection.

Conclusion

During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway.

The effect of multiplicity of PI-RADS 3 lesions on cancer detection rate of confirmatory targeted biopsy in patients diagnosed with prostate cancer and managed with active surveillance

BACKGROUND AND OBJECTIVE

To determine the effect of multiplicity of prostate imaging reporting and data system assessment category 3 (PI-RADS 3) lesions on cancer detection rate (CDR) of confirmatory targeted biopsy of such lesion in patients diagnosed with prostate cancer and managed with active surveillance.

METHODS

This study was conducted at a single academic institution. There were 91 men with ≥ 1 PI-RADS 3 lesion detected through magnetic resonance imaging (MRI) after systematic prostate biopsy in the course of management of patients diagnosed with prostate cancer with active surveillance. We compared the CDRs based on targeted biopsy of PI-RADS 3 lesions that occurred (1) as solitary lesions, (2) as 1 of multiple PI-RADS 3 only lesions, or (3) with ≥ 1 higher grade lesion.

RESULTS

Median age was 65.0 years (interquartile range 59.5-70.0), median prostate specific antigen was 5.95 ng/ml (interquartile range 4.30-8.83), and median prostate specific antigen density was 0.161 ng/ml² (0.071-0.194). Forty-three men had solitary PI-RADS 3 lesions, 22 had multiple PI-RADS 3 only lesions, and 26 had multiple lesions with ≥ 1 higher grade lesion. The overall CDR (Gleason score ≥ 3 + 3) based on confirmatory MRI targeted biopsy in a given PI-RADS 3 lesion in each group was 23%, 45%, and 54%, respectively (P = 0.0274). The CDRs for clinically significant disease (Gleason score ≥ 3 + 4) were 16%, 32%, and 35%, respectively (P = 0.1701).

CONCLUSIONS

Coexisting lesions increase the CDR of confirmatory MRI targeted biopsy of PI-RADS 3 lesions in patients managed with active surveillance. Risk stratification algorithms for PI-RADS 3 lesion to guide biopsy and management decisions may consider including multiplicity of lesions.

Tumor mutational burden predicts survival in patients with low-grade gliomas expressing mutated IDH1

Background

Gliomas are the most common primary brain tumors. High-Grade Gliomas have a median survival (MS) of 18 months, while Low-Grade Gliomas (LGGs) have an MS of approximately 7.3 years. Seventy-six percent of patients with LGG express mutated isocitrate dehydrogenase (mIDH) enzyme. Survival of these patients ranges from 1 to 15 years, and tumor mutational burden ranges from 0.28 to 3.85 somatic mutations/megabase per tumor. We tested the hypothesis that the tumor mutational burden would predict the survival of patients with tumors bearing mIDH.

Methods

We analyzed the effect of tumor mutational burden on patients' survival using clinical and genomic data of 1199 glioma patients from The Cancer Genome Atlas and validated our results using the Glioma Longitudinal AnalySiS consortium.

Results

High tumor mutational burden negatively correlates with the survival of patients with LGG harboring mIDH (P = .005). This effect was significant for both Oligodendroglioma (LGG-mIDH-O; MS = 2379 vs 4459 days in high vs low, respectively; P = .005) and Astrocytoma (LGG-mIDH-A; MS = 2286 vs 4412 days in high vs low respectively; P = .005). There was no differential representation of frequently mutated genes (eg, TP53, ATRX, CIC, and FUBP) in either group. Gene set enrichment analysis revealed an enrichment in Gene Ontologies related to cell cycle, DNA-damage response in high versus low tumor mutational burden. Finally, we identified 6 gene sets that predict survival for LGG-mIDH-A and LGG-mIDH-O.

Conclusions

we demonstrate that tumor mutational burden is a powerful, robust, and clinically relevant prognostic factor of MS in mIDH patients.

Detection of significant prostate cancer through magnetic resonance imaging targeted biopsy of PI-RADS3 lesions in African American patients based on prostate specific antigen density threshold of 0.15 ng/ml2: Analysis of patient population from the Vattikuti Urology Institute

286

Background: A prostate specific antigen density (PSAD) threshold of 0.15 ng/ml2 have been suggested for significant cancer detection in PI-RADS 3 lesions to avoid unnecessary magnetic resonance imaging targeted biopsy (MRI-TB) of these lesions. However, the performance of this threshold in African American (AA) patients is not well characterized. Methods: We analyzed our institutional data base of MRI-TB to identify the rate of significant prostate cancer (Pca) detection in PI-RADS3 lesions in AA patients stratified by PSAD threshold of < 0.15 vs. ≥0.15 ng/ml2 and lesion size of < 1 cm vs ≥ 1 cm. Significant prostate cancer was defined as Gleason grade group 2 or higher on MRI-TB of the PI-RADS 3 lesion. Results: Of 768 patients included in the database, 211 (27.5%) patients identified themselves as AAs. Mean age of AA patients was 63 years and mean PSAD was 0.21. Sixty nine (32.7%) AA patients were found to have PI-RADS 3 lesions. Mean PSAD of AA patients with PI-RADS 3 lesions was 0.21 ng/ml2 as well. Fifty percent of AA patients with PI-RADS 3 lesions had PSAD ≥0.15 ng/ml2. Significant Pca detection rate for AA patients with PI-RADS 3 lesions was 9% for PSAD of ≥ 0.15 vs. 0.03% percent for AA patients with PSAD < 0.15 ng/ml2 (OR 7.056, CI 1.017-167.9, P=0.04). Stratification by lesion size (< 1 cm vs. > 1 cm) resulted in missing 0% percentage of significant Pca when only AA patients with PSAD ≥ 0.15 ng/ml2 and lesion size ≥ 1 cm received MRI-TB. Conclusions: We report on the performance of a reported PSAD density threshold in detecting significant Pca in one of the largest series of AA patients receiving MRI-TB of the prostate. Our results have direct clinical implications when counseling AA patients with PI-RADS 3 lesion on whether they should undergo MRI-TB of such lesions.

Barriers to obtaining prostate multi-parametric magnetic resonance imaging in African-American men on active surveillance for prostate cancer

Purpose

Magnetic resonance imaging is playing an ever‐bigger role in the management of prostate cancer. This study investigated barriers to obtaining multi‐parametric MRI (mpMRI) in African‐American men on active surveillance for prostate cancer in comparison to white men affected by the same type of cancer.

Materials and Methods

Retrospective review of prostate mpMRI orders from August 2015 to October 2017 at a single health organization treating a diverse population was performed. Data was extracted from the electronic medical records and cancellations were examined based on the documented reason for mpMRI cancellation, race, median zip code household income, and distance from healthcare facility.

Results

Out of 793 prostate mpMRI orders, 201 (25%) went unscanned. Access to care issues accounted for 46% of unscanned orders. Patient cancellations were the most common, followed by difficulty contacting patients, and insurance denials. African‐American patients disproportionately went unscanned because institution staff were unable to contact patients (29% vs 10% in white men, P = 0.0015). Median zip code household income was significantly different between racial groups but did not vary between indication for cancellation.

Conclusions

African‐American prostate cancer patients' access to mpMRI is hindered more by barriers to care than White patients. Urology providers must consider these issues before using prostate mpMRI within their active surveillance pathways.

Prostate volume measured by magnetic resonance imaging is not a predictor of lower urinary tract symptoms

Purpose:

Prostate volume is frequently utilized to counsel patients presenting to family medicine physicians with voiding complaints. We evaluated the relation between International Prostate Symptom Score (IPSS) and prostate volume measured by phased-array surface coil magnetic resonance imaging (MRI).

Methods:

We performed an institutional review board (IRB)–approved retrospective study of all patients who received a prostate MRI between 2015 and 2017. Correlation between the overall IPSS, IPSS components, prostate volume stratified by prostate specific antigen (PSA) (<1.4 vs. ≥1.4 g/dL), and race (black vs. white) was examined.

Results:

In all, 592 patients had prostate MRIs performed between 2015 and 2017. Two hundred and twenty-nine of these patients had IPSS and prostate volume information available in their medical records. The mean age of the cohort was 64.67 (SD = ±7.82) and mean PSA was 7.75 (SD = ±8.3). The mean IPSS was 9.77 (SD ± 7.2), and mean prostate volume was 55.88 cubic cm (SD = ±38.9). The correlation coefficient between prostate volume and IPSS was 0.12789 (P = 0.05). The correlation between prostate volume and IPSS was also not significant in 128 men with prostate volume above 40 cubic cm. Stratifying analysis by race and PSA showed no significant correlation between volume and IPSS. Analysis of the correlation between the different dimension of prostate volume and IPSS revealed significant but weak associations.

Conclusions:

Even with more precise estimation with MRI, prostate volume does not predict obstruction complaints. This finding is of importance when treating males presenting with voiding dysfunction to primary care.

A prospective study to examine the association of the urinary and fecal microbiota with prostate cancer diagnosis after transrectal biopsy of the prostate using 16sRNA gene analysis

INTRODUCTION

There is accumulating evidence that variations in the human microbiota may promote disease states including cancer. Our goal was to examine the association between urinary and fecal microbial profiles and the diagnosis of prostate cancer (PC) in patients undergoing transrectal biopsy of the prostate.

MATERIALS AND METHODS

We extracted total DNA from urine and fecal samples collected before a prostate biopsy performed for elevated prostatic specific antigen in patients suspected of having PC. We then amplified the extracted DNA and sequenced it using bacterial 16S rRNA gene high-throughput next-generation sequencing platform, and analyzed microbial profiles for taxonomy comparing those patients diagnosed with PC with those who did not receive that diagnosis.

RESULTS

We included 30 patients in our analysis (60 samples, one urine and one fecal per patient). The majority of patients with PC (10/14) had similar bacterial communities within their urinary sample profile and clustered separately than patients without cancer (n = 16). Differential analysis of the operational taxonomical units (OTUs) in urine samples revealed decreased abundance of several bacterial species in patients with prostate cancer. Analysis of the bacterial taxonomies of the fecal samples did not reveal any clustering in concordance with benign or malignant prostate biopsies. Patients who had a Gleason score (GS) of 6 (n = 11) were present in both urine bacterial community clusters, but patients with GS 7 or higher (n = 3) did not cluster tightly with non-cancer subjects.

CONCLUSIONS

The urinary microbiota of patients with PC tends to cluster separately from those without this disease. Further research is needed to investigate the urinary microbiome potential of serving as a biomarker that could be used to improve the accuracy of pre-biopsy models predicting the presence of PC in post-biopsy tissue examination.

Endocrine, Sexual Function, and Infertility Side Effects of Immune Checkpoint Inhibitor Therapy for Genitourinary Cancers

PURPOSE OF REVIEW

Immune checkpoint therapy has grown in prominence in the last few decades and is being increasingly utilized in treatment of advanced cancers. Although information on toxicities of these drugs is forthcoming, not much is known regarding the toxicity profile of these drugs from a sexual function standpoint. We undertook the current review to appraise the literature for endocrine/sexual side effects of anti-PD-1/PD-L1 and anti-CTLA-4 therapy.

RECENT FINDINGS

Our review included 32 articles and focused primarily on the programmed death (PD) pathway. We found that endocrine side effects after anti-PD-1/PD-L1 therapy are relatively rare, with hypothyroidism (range < 1 to 40%) and hypophysitis (range < 1 to 10%) being the two most common. None of the studies specifically commented on the infertility or sexual side effects of these drugs. However, two studies evaluating biochemical profiles of patients undergoing therapy with ipilimumab (a CTLA-4 inhibitor) or combination therapy (CTLA-4 + PD-1/PD-L1 inhibitors) noted that about < 1 to ~ 60% of the patients developed hypogonadotropic hypogonadism. None of the studies provided information regarding clinically meaningful sexual health endpoints such as libido, erectile function assessments, or sexual function-related quality of life. Endocrine side effects, although uncommon, are important and unique side effects of immune checkpoint therapy because they are often complex and can be life threatening. While side effects on sexual health may not be life threatening, they are lifestyle limiting. Thus, long-term follow-up, post-marketing surveillance, and future studies will need to elucidate the true rates of endocrine/sexual side effects and the mechanisms underlying them. This will aid in better counseling of the patients, as more of them undergo these novel immune checkpoint inhibitor therapies.

Ubiquitin Specific Protease 26 (USP26) expression analysis in human testicular and extragonadal tissues indicates diverse action of USP26 in cell differentiation and tumorigenesis

Ubiquitin specific protease 26 (USP26), a deubiquitinating enzyme, is highly expressed early during murine spermatogenesis, in round spermatids, and at the blood-testis barrier. USP26 has also been recognized as a regulator of androgen receptor (AR) hormone-induced action involved in spermatogenesis and steroid production in in vitro studies. Prior mutation screening of USP26 demonstrated an association with human male infertility and low testosterone production, but protein localization and expression in the human testis has not been characterized previously. USP26 expression analysis of mRNA and protein was completed using murine and human testis tissue and human tissue arrays. USP26 and AR mRNA levels in human testis were quantitated using multiplex qRT-PCR. Immunofluorescence colocalization studies were performed with formalin-fixed/paraffin-embedded and frozen tissues using primary and secondary antibodies to detect USP26 and AR protein expression. Human microarray dot blots were used to identify protein expression in extra-gonadal tissues. For the first time, expression of USP26 and colocalization of USP26 with androgen receptor in human testis has been confirmed predominantly in Leydig cell nuclei, with less in Leydig cell cytoplasm, spermatogonia, primary spermatocytes, round spermatids, and Sertoli cells. USP26 likely affects regulatory proteins of early spermatogenesis, including androgen receptor with additional activity in round spermatids. This X-linked gene is not testis-specific, with USP26 mRNA and protein expression identified in multiple other human organ tissues (benign and malignant) including androgen-dependent tissues such as breast (myoepithelial cells and secretory luminal cells) and thyroid tissue (follicular cells). USP26/AR expression and interaction in spermatogenesis and androgen-dependent cancer warrants additional study and may prove useful in diagnosis and management of male infertility.

Enuretic children with obstructive sleep apnea syndrome: should they see otolaryngology first?

OBJECTIVES

To study: (1) the prevalence of diurnal urinary incontinence (DI) and nocturnal enuresis (NE) in children with obstructive sleep apnea syndrome (OSAS) who underwent surgery for their upper airway symptoms, (2) the postoperative rate of enuresis resolution, and (3) factors that may predict lack of improvement post surgery.

PATIENTS AND METHODS

An observational, pilot study of children 5-18 years of age with OSAS and NE who underwent tonsillectomy and/or adenoidectomy (T&A) between 2008 and 2010 was performed. Study consisted of a phone interview and chart review. Severity of NE and DI, frequency, arousal and sleeping disturbances were assessed pre and post T&A. Factors associated with failure to respond were analyzed using a logistic regression model.

RESULTS

Among the 417 children who underwent T&A, 101 (24%) had NE (61 males, mean age 7.8 ± 2.5 years), and of these 24 had associated DI (6%). Mean postoperative follow-up was 11.7 months. Of the 49 whose NE responded to T&A (49%), 30 resolved within 1 month postoperatively. DI resolved in 4 children (17%). There was a statistically significant difference between responders and non-responders regarding the presence of prematurity, obesity, family history of NE, type of enuresis, enuresis severity, and ability to be easily aroused.

CONCLUSION

NE was present in about one fourth of children with OSAS undergoing surgery, and resolved in about half. Lower response rate was associated with prematurity, obesity, family history of NE, presence of non-monosymptomatic NE, severe NE preoperatively, and arousal difficulties.

Robot-assisted urological surgery: Current status and future perspectives

Objectives

To discuss the current status of robot-assisted urological surgery.

Methods

We searched PubMed for articles published from 2008 using the search terms ‘advances’, ‘robotic surgery equipment’ and ‘instrumentation’. We also searched PubMed for articles describing the latest developments in reconstructive techniques for lower and upper urinary tract procedures. Finally, we searched PubMed for original articles containing the terms ‘robotic surgery training’ and ‘credentialing’.

Results

With each release of hardware or ancillary instrumentation, the reconstructive abilities of the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) improve. Recent developments in reconstructive capabilities of robotic urological surgery include posterior reconstruction during robot-assisted radical prostatectomy, barbed sutures for urethrovesical anastomosis, sliding-clip renorrhaphy for robot-assisted partial nephrectomy, and repair of pelvic organ prolapse. The safe implementation of robotic surgery is aided by new guidelines in credentialing and proctoring, and the introduction of virtual reality simulators for training.

Conclusion

Robotic urological surgery is rapidly developing and expanding globally. To achieve the highest levels of safety for patients, surgeons must ensure that the implementation of robotic surgery is an integrative and effective process.

Does increasing number of core biopsies change the results of needle biospy in prostate cancer?

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Background: The superiority of extended sampling of the prostate compared to standard sextant biopsy in predicting the final Gleason score has been controversial. In the literature, sextant biopsies have a match rate between 28–68% and an upgrading rate of 25–57%. Consequently, multiple studies recommend that extended biopsies should be the standard of care. This study examines the effect of greater core biopsy number on upgrading GS and predicting surgical pathology.

Methods: Prostate biopsies of 984 patients who underwent RP between 2001 and 2008 were retrospectively reviewed. The GS of the biopsies was compared to the pathological specimens using the Chi-square test. Further adjusted comparison was performed using logistic regression. A clinical significant upgrade was defined as increase of the total GS or the primary GS.

Results: The majority of the upgrading occurred in biopsy Gleason 3+3 and 3+4 cases. Upgrading was seen in 35.1% of patients with 6 cores or less, 34.5% with 7–12 cores, and 45.5% with 13+ cores (p=0.061). Number of cores, BMI, or prostate size did not affect upgrading, while perineural invasion, cancer volume on a biopsy, and D'Amico risk criteria increased the likelihood of upgrading.

Conclusions: The extended core biopsy does not seem to correlate with higher gleason score or to better predict the final pathologic gleason score compared to standard sextant biopsies in prostate cancer. D'Amico risk factors, perineural invasion, and cancer volume can be viewed as risk factors for upgrading especially in GS 3+3.

No significant financial relationships to disclose.

Prognostic indicators of aggressive disease in patients with locally advanced or metastatic prostate cancer: A focus on neutrophil to lymphocyte and platelet to lymphocyte ratios

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Background: Prostate specific antigen (PSA) and Gleason Score (GS) are helpful in predicting aggressive disease. Recently, the neutrophil:lymphocyte ratio (NLR) and platlet:lymphocyte ratio (PLR) were identified as prognostic indicators in gastric cancer which has an inflammatory pathogenesis. We hypothesized that these indicators may be prognostic in prostate cancer which is also postulated to have an inflammatory mechanism of carcinogenesis. Our goal was to assess if NLR and PLR is predictive of aggressive prostate cancer, which will be measured by metastasis and overall survival in patients on hormonal therapy as treatment.

Methods: We performed a retrospective analysis of 246 patients that were being treated with hormone therapy for either locally advanced or metastatic disease, or who were not surgical candidates or refused surgery. A logistic regression model was used to analyze various prognostic factors including total GS, pre-biopsy PSA, perineural invasion, % of core biopsies positive, NLR, and PLR. Endpoints studied were overall survival and metastasis.

Results: The logistic regression showed only pre biopsy PSA as a predictor of metastasis (n=82). The increased risk when measured continuously was 0.6% increase in odds ratio (p<0.015). When PSA was measured categorically the % biopsy cores positive were predictive of increased risk of metastatic disease with a 2.9% increase in odds ratio (p<0.002). The % biopsy cores positive were predictive of a 3.7% increased odds ratio in cancer-specific mortality (p<0.002). These results were controlled for age, which gave a 7% increase in odds ratio of overall survival (p<0.049).

Conclusions: Despite the thought that prostate cancer has an inflammatory pathogenesis, no correlation was found between N:L and P:L ratios and overall survival or bone metastasis in patients on hormone therapy for locally advanced disease. There was a negative correlation between increased % positive biopsy cores a decreased risk of survival. Further investigation is necessary to investigate the role of NLR and PLR as prognostic indicators in organ confined prostate cancer.

No significant financial relationships to disclose.