A Multicenter Prospective Randomized Controlled Trial Comparing Cxbladder Triage to Cystoscopy in Patients With Microhematuria. The Safe Testing of Risk for Asymptomatic Microhematuria Trial

PURPOSE

AUA guidelines for patients with microhematuria (≥3 red blood cells [RBC]/high-power field [hpf]) include cystoscopy for most over age 40 due to risk of urothelial cancer (UC). Cxbladder Triage (CxbT) is a urinary genomic test with UC negative predictive value of 99%. In this prospective randomized controlled trial, we compared cystoscopy use in a standard of care (SOC) arm vs a marker-based approach.

MATERIALS AND METHODS

All patients with hematuria provided urine for a CxbT. Those categorized as lower risk (LR), defined as 3 to 29 RBC/hpf and minimal smoking history (<10 pack-years) were randomized between the test group provided with the CxbT result vs the SOC control group. Negative CxbT patients were offered omission of cystoscopy with surveillance. "Not lower risk" (NLR) patients (>30 RBC/hpf or >10 pack-year smoking history) had a CxbT but otherwise SOC. Patient decision and outcomes were recorded.

RESULTS

Of 390 eligible patients, 255 were NLR and 135 were LR randomized to CxbT informed decision or SOC. The median age was 62 years (range 18-94) and 54% were male. Overall, 63% of CxbT tests were negative. For NLR patients, 82% had cystoscopy. In the LR control group, cystoscopy was performed in 67% of SOC and 27% in the test group (relative risk 0.41 [95% CI 0.27-0.61]). Compared to cystoscopy, CxbT had 90% sensitivity, 56% specificity, and 99% negative predictive value for UC.

CONCLUSIONS

In this prospective randomized controlled trial, use of CxbT in patients with LR hematuria resulted in 59% reduction of cystoscopy use. This clinical utility of Cxbladder Triage can reduce the burden of unnecessary cystoscopies.

LensePro: label noise-tolerant prototype-based network for improving cancer detection in prostate ultrasound with limited annotations

PURPOSE

The standard of care for prostate cancer (PCa) diagnosis is the histopathological analysis of tissue samples obtained via transrectal ultrasound (TRUS) guided biopsy. Models built with deep neural networks (DNNs) hold the potential for direct PCa detection from TRUS, which allows targeted biopsy and subsequently enhances outcomes. Yet, there are ongoing challenges with training robust models, stemming from issues such as noisy labels, out-of-distribution (OOD) data, and limited labeled data.

METHODS

This study presents LensePro, a unified method that not only excels in label efficiency but also demonstrates robustness against label noise and OOD data. LensePro comprises two key stages: first, self-supervised learning to extract high-quality feature representations from abundant unlabeled TRUS data and, second, label noise-tolerant prototype-based learning to classify the extracted features.

RESULTS

Using data from 124 patients who underwent systematic prostate biopsy, LensePro achieves an AUROC, sensitivity, and specificity of 77.9%, 85.9%, and 57.5%, respectively, for detecting PCa in ultrasound. Our model shows it is effective for detecting OOD data in test time, critical for clinical deployment. Ablation studies demonstrate that each component of our method improves PCa detection by addressing one of the three challenges, reinforcing the benefits of a unified approach.

CONCLUSION

Through comprehensive experiments, LensePro demonstrates its state-of-the-art performance for TRUS-based PCa detection. Although further research is necessary to confirm its clinical applicability, LensePro marks a notable advancement in enhancing automated computer-aided systems for detecting prostate cancer in ultrasound.

Standardization of the evaluation and surveillance of patients with BCG unresponsive high grade non-muscle invasive bladder cancer clinical trials

There are multiple ongoing and planned clinical trials that are evaluating novel therapies to treat patients with BCG-unresponsive high grade nonmuscle invasive bladder cancer (NMIBC). Importantly, there is considerable variation in surveillance strategies between these clinical trials, specifically with regards to the use of advanced imaging, enhanced cystoscopy, and mandatory biopsies, which could impact landmark efficacy assessments of investigational agents. To present guideline recommendations for the standardization of cystoscopic evaluation, surveillance, and efficacy assessments for patients with BCG-unresponsive NMIBC participating in clinical trials. On September 29, 2023 at the annual meeting of the International Bladder Cancer Network, a breakout session was convened, during which representatives from various disciplines discussed potential guidance statements with opportunity for discussion and comment. A set of statements regarding use of white light and enhanced cystoscopy were developed to help guide a pragmatic approach to surveillance and efficacy assessments of patients in clinical trials. The use of "for cause" and "mandatory" biopsies was also addressed. A standard approach to evaluation of patients within the context of clinical trials is necessary to accurately assess the efficacy of novel agents, especially within single arm trials that lack an appropriate comparator. Additionally, the utilization and timing of mandatory biopsies is critical, as these biopsies may impact both disease evaluations and the determination of duration of response.

Quantifying the Impact of Cancer on the Viscoelastic Properties of the Prostate Gland using a Quasi-Linear Viscoelastic Model

Pathological disorders can alter the mechanical properties of biological tissues, and studying such changes can help to better understand the disease progression. The prostate gland is no exception, as previous studies have shown that cancer can affect its mechanical properties. However, most of these studies have focused on the elastic properties of the tissue and have overlooked the impact of cancer on its viscous response. To address this gap, we used a quasi-linear viscoelastic model to investigate the impact of cancer on both the elastic and viscous characteristics of the prostate gland. By comparing the viscoelastic properties of segments influenced by cancer and those unaffected by cancer in 49 fresh prostates, removed within two hours after prostatectomy surgery, we were able to determine the influence of cancer grade and tumor volume on the tissue. Our findings suggest that tumor volume significantly affects both the elastic modulus and viscosity of the prostate (p-value less than 2%). Specifically, we showed that cancer increases Young's modulus and shear relaxation modulus by 20%. These results have implications for using mechanical properties of the prostate as a potential biomarker for cancer. However, developing an in vivo apparatus to measure these properties remains a challenge that needs to be addressed in future research. STATEMENT OF SIGNIFICANCE: This study is the first to explore how cancer impacts the mechanical properties of prostate tissues using a quasi-linear viscoelastic model. We examined 49 fresh prostate samples collected immediately after surgery and correlated their properties with cancer presence identified in pathology reports. Our results demonstrate a 20% change in the viscoelastic properties of the prostate due to cancer. We initially validated our approach using tissue-mimicking phantoms and then applied it to differentiate between cancerous and normal prostate tissues. These findings offer potential for early cancer detection by assessing these properties. However, conducting these tests in vivo remains a challenge for future research.

Comparison of physics-based deformable registration methods for image-guided neurosurgery

This paper compares three finite element-based methods used in a physics-based non-rigid registration approach and reports on the progress made over the last 15 years. Large brain shifts caused by brain tumor removal affect registration accuracy by creating point and element outliers. A combination of approximation- and geometry-based point and element outlier rejection improves the rigid registration error by 2.5 mm and meets the real-time constraints (4 min). In addition, the paper raises several questions and presents two open problems for the robust estimation and improvement of registration error in the presence of outliers due to sparse, noisy, and incomplete data. It concludes with preliminary results on leveraging Quantum Computing, a promising new technology for computationally intensive problems like Feature Detection and Block Matching in addition to finite element solver; all three account for 75% of computing time in deformable registration.

Real-Time Dynamic Data Driven Deformable Registration for Image-Guided Neurosurgery: Computational Aspects

Current neurosurgical procedures utilize medical images of various modalities to enable the precise location of tumors and critical brain structures to plan accurate brain tumor resection. The difficulty of using preoperative images during the surgery is caused by the intra-operative deformation of the brain tissue (brain shift), which introduces discrepancies concerning the preoperative configuration. Intra-operative imaging allows tracking such deformations but cannot fully substitute for the quality of the pre-operative data. Dynamic Data Driven Deformable Non-Rigid Registration (D4NRR) is a complex and time-consuming image processing operation that allows the dynamic adjustment of the pre-operative image data to account for intra-operative brain shift during the surgery. This paper summarizes the computational aspects of a specific adaptive numerical approximation method and its variations for registering brain MRIs. It outlines its evolution over the last 15 years and identifies new directions for the computational aspects of the technique.

Universal DNA methylation age across mammalian tissues

Aging, often considered a result of random cellular damage, can be accurately estimated using DNA methylation profiles, the foundation of pan-tissue epigenetic clocks. Here, we demonstrate the development of universal pan-mammalian clocks, using 11,754 methylation arrays from our Mammalian Methylation Consortium, which encompass 59 tissue types across 185 mammalian species. These predictive models estimate mammalian tissue age with high accuracy (r > 0.96). Age deviations correlate with human mortality risk, mouse somatotropic axis mutations and caloric restriction. We identified specific cytosines with methylation levels that change with age across numerous species. These sites, highly enriched in polycomb repressive complex 2-binding locations, are near genes implicated in mammalian development, cancer, obesity and longevity. Our findings offer new evidence suggesting that aging is evolutionarily conserved and intertwined with developmental processes across all mammals.

DNA methylation networks underlying mammalian traits

Using DNA methylation profiles (n = 15,456) from 348 mammalian species, we constructed phyloepigenetic trees that bear marked similarities to traditional phylogenetic ones. Using unsupervised clustering across all samples, we identified 55 distinct cytosine modules, of which 30 are related to traits such as maximum life span, adult weight, age, sex, and human mortality risk. Maximum life span is associated with methylation levels in HOXL subclass homeobox genes and developmental processes and is potentially regulated by pluripotency transcription factors. The methylation state of some modules responds to perturbations such as caloric restriction, ablation of growth hormone receptors, consumption of high-fat diets, and expression of Yamanaka factors. This study reveals an intertwined evolution of the genome and epigenome that mediates the biological characteristics and traits of different mammalian species.

Surgery in Early Metastatic Seminoma: A Phase II Trial of Retroperitoneal Lymph Node Dissection for Testicular Seminoma With Limited Retroperitoneal Lymphadenopathy

PURPOSE

The long-term toxicities of chemotherapy and radiotherapy can represent a significant burden to testicular cancer survivors. Retroperitoneal lymph node dissection (RPLND) is an established treatment for testicular germ cell tumors with minimal late morbidity although little data exist on its efficacy in early metastatic seminoma. Surgery in early metastatic seminoma is a prospective phase II single-arm, multi-institutional trial of RPLND as first-line treatment for testicular seminoma with clinically low-volume retroperitoneal lymphadenopathy.

PATIENTS AND METHODS

Twelve sites in the United States and Canada prospectively enrolled adult patients with testicular seminoma and isolated retroperitoneal lymphadenopathy (1-3 cm). Open RPLND was performed by certified surgeons with a primary end point of 2-year recurrence-free survival (RFS). Complication rates, pathologic up/downstaging, recurrence patterns, adjuvant therapies, and treatment-free survival were assessed.

RESULTS

A total of 55 patients were enrolled, with a median (IQR) largest clinical lymph node size of 1.6 cm (1.3-1.9). RPLND pathology demonstrated a median (IQR) largest lymph node size of 2.3 cm (0.9-3.5); nine patients (16%) were pN0, 12 (22%) pN1, 31 (56%) pN2, and 3 (5%) pN3. One patient received adjuvant chemotherapy. With a median (IQR) follow-up of 33 months (12.0-61.6), 12 patients experienced recurrence, with a 2-year RFS of 81% and a recurrence rate of 22%. Of the patients who experienced recurrence, 10 were treated with chemotherapy and two underwent additional surgery. At last follow-up, all patients who experienced a recurrence were disease-free and the 2-year overall survival was 100%. Four patients (7%) experienced short-term complications, and four patients experienced long-term complications including incisional hernia (1) and anejaculation (3).

CONCLUSION

RPLND is a treatment option for testicular seminoma with clinically low-volume retroperitoneal lymphadenopathy and is associated with low long-term morbidity.

Urinary Analysis of FGFR3 and TERT Gene Mutations Enhances Performance of Cxbladder Tests and Improves Patient Risk Stratification

PURPOSE

Cxbladder tests are urinary biomarker tests for detection of urothelial carcinoma. We developed enhanced Cxbladder tests that incorporate DNA analysis of 6 single nucleotide polymorphisms for the FGFR3 and TERT genes, in addition to the current 5 mRNA biomarkers and clinical risk factors.

MATERIALS AND METHODS

Two multicenter, prospective studies were undertaken in: (1) U.S. patients with gross hematuria aged ≥18 years and (2) Singaporean patients with gross hematuria or microhematuria aged >21 years. All patients provided a midstream urine sample and underwent cystoscopy. Samples were retrospectively analyzed using enhanced Cxbladder-Triage (risk stratifies patients), enhanced Cxbladder-Detect (risk stratifies patients and detects positive patients), and the combination enhanced Cxbladder-Triage × Cxbladder-Detect.

RESULTS

In the pooled cohort (N=804; gross hematuria: n=484, microhematuria: n=320), enhanced Cxbladder-Detect had a sensitivity of 97% (95% CI 89%-100%), specificity of 90% (95% CI 88%-92%), and negative predictive value of 99.7% (95% CI 99%-100%) for detection of urothelial carcinoma. Overall, 83% of patients were enhanced Cxbladder-Detect-negative (ie, needed no further work-up). Of 133 enhanced Cxbladder-Detect-positive patients, 59 had a confirmed tumor, of which 19 were low-grade noninvasive papillary carcinoma or papillary urothelial neoplasm of low malignant potential. In total, 40 tumors were high-grade Ta, T1-T4, Tis, including concomitant carcinoma in situ. Of the 74 patients with normal cystoscopy, 41 were positive by single nucleotide polymorphism analysis. Enhanced Cxbladder-Triage and enhanced Cxbladder-Detect had significantly better specificity than the first-generation Cxbladder tests (P < .001).

CONCLUSIONS

This study in ethnically diverse patients with hematuria showed the analytical validity of the enhanced Cxbladder tests.

Predictive Biomarkers of Response to Neoadjuvant Therapy in Muscle Invasive Bladder Cancer

Neoadjuvant cisplatin-based chemotherapy is recommended prior to surgical removal of the bladder for patients with non-metastatic muscle invasive bladder cancer. Despite a survival benefit, approximately half of patients do not respond to chemotherapy and are exposed potentially unnecessarily to substantial toxicity and delay in surgery. Therefore, biomarkers to identify likely responders before initiating chemotherapy would be a helpful clinical tool. Furthermore, biomarkers may be able to identify patients who do not need subsequent surgery after clinical complete response to chemotherapy. To date, there are no clinically approved predictive biomarkers of response to neoadjuvant therapy. Recent advances in the molecular characterization of bladder cancer have shown the potential role for DNA damage repair (DDR) gene alterations and molecular subtypes to guide therapy, but these need validation from prospective clinical trials. This chapter reviews candidate predictive biomarkers of response to neoadjuvant therapy in muscle invasive bladder cancer.

Intra-individual comparison of 18F-sodium fluoride PET-CT and 99mTc bone scintigraphy with SPECT in patients with prostate cancer or breast cancer at high risk for skeletal metastases (MITNEC-A1): a multicentre, phase 3 trial

BACKGROUND

Detection of skeletal metastases in patients with prostate cancer or breast cancer remains a major clinical challenge. We aimed to compare the diagnostic performance of ^99mTc-methylene diphosphonate (^99mTc-MDP) single-photon emission CT (SPECT) and ¹⁸F-sodium fluoride (¹⁸F-NaF) PET-CT for the detection of osseous metastases in patients with high-risk prostate or breast cancer.

METHODS

MITNEC-A1 was a prospective, multicentre, single-cohort, phase 3 trial conducted in ten hospitals across Canada. Patients aged 18 years or older with breast or prostate cancer with a WHO performance status of 0-2 and with high risk or clinical suspicion for bone metastasis, but without previously documented bone involvement, were eligible. ¹⁸F-NaF PET-CT and ^99mTc-MDP SPECT were done within 14 days of each other for each participant. Two independent reviewers interpreted each modality without knowledge of other imaging findings. The primary endpoint was the overall accuracy of ^99mTc-MDP SPECT and ¹⁸F-NaF PET-CT scans for the detection of bone metastases in the per-protocol population. A combination of histopathological, clinical, and imaging follow-up for up to 24 months was used as the reference standard to assess the imaging results. Safety was assessed in all enrolled participants. This study is registered with ClinicalTrials.gov, NCT01930812, and is complete.

FINDINGS

Between July 11, 2014, and March 3, 2017, 290 patients were screened, 288 of whom were enrolled (64 participants with breast cancer and 224 with prostate cancer). 261 participants underwent both ¹⁸F-NaF PET-CT and ^99mTc-MDP SPECT and completed the required follow-up for statistical analysis. Median follow-up was 735 days (IQR 727-750). Based on the reference methods used, 109 (42%) of 261 patients had bone metastases. In the patient-based analysis, ¹⁸F-NaF PET-CT was more accurate than ^99mTc-MDP SPECT (84·3% [95% CI 79·9-88·7] vs 77·4% [72·3-82·5], difference 6·9% [95% CI 1·3-12·5]; p=0·016). No adverse events were reported for the 288 patients recruited.

INTERPRETATION

¹⁸F-NaF has the potential to displace ^99mTc-MDP as the bone imaging radiopharmaceutical of choice in patients with high-risk prostate or breast cancer.

FUNDING

Canadian Institutes of Health Research.

Oncological Outcomes for Patients Harboring Positive Surgical Margins Following Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Retrospective Multicentric Study on Behalf of the YAU Urothelial Group

Introduction: Adjuvant therapy has no defined role for patients with positive surgical margins (PSMs) following radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). The aim of our study was to describe loco-regional recurrence-free survival (LRFS), metastatic-free survival (MFS), recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) and identify predictors of each endpoint in patients with PSMs following RC for MIBC. Methods: A collaborative retrospective cohort study was conducted on 394 patients with PSMs who underwent RC for MIBC between January 2000 and December 2018 at 10 tertiary referral centers. Patients receiving perioperative radiotherapy were excluded from the study. Kaplan−Meier curves were used to estimate patient survival. Cox regression analysis was used to identify predictors of survival. Results: Median age at surgery was 70 years (IQR 62−76) with 129 (33%) and 204 (52%) patients had pT3 and pT4 tumors, respectively. Nodal metastasis (pN+) was identified in 148 (38%). Soft tissue PSMs were found in 283 (72%) patients, urethral PSMs in 65 (16.5%), and ureteral PSMs were found in 73 (18.5%). The median follow-up time was 44 months (95% CI 32−60). Median LRFS, MRFS, RFS, CSS, and OS were 14 (95% CI 11−17), 12 (95% CI 10−16), 10 (95% CI 8−12), 23 (95% CI 18−33), and 16 months (95% CI 12−19), respectively. On multivariable Cox regression analysis, the pT3−4 stage, pN+ stage, and multifocal PSMs were independent predictors of LRFS, MRFS, RFS, and OS. Adjuvant chemotherapy improved all oncological outcomes studied (p < 0.05). The number of lymph nodes removed was independently associated with better LRFS, MRFS, and RFS. Advanced age at diagnosis was independently associated with worse OS. Conclusion: Patients with PSMs following RC have poor outcomes since half of them will recur within a year and will die of their disease. Among all PSMs types, patients with multifocal PSMs harbor the worst prognosis. We observed a benefit of adjuvant chemotherapy, but clinical trials evaluating innovative adjuvant strategies for these patients remain an unmet need.

Healthcare professionals knowledge of inherited cardiac arrhythmias ica their views towards and confidence in caring for a person with an ica in a surgical environment

Background

Inherited Cardiac Arrhythmias (ICA) are potentially life-threatening conditions which may be induced by several factors during the perioperative period. Safety and quality of care of patients may be affected by insufficient knowledge, or confidence by healthcare professionals in surgical areas.

Purpose

To determine the knowledge of ICAs by healthcare professionals, their views towards and confidence in caring for a person with an ICA in a surgical environment.

Methods

In Phase One, a twenty-four item questionnaire was distributed to registered nurses and midwives, surgeons and anaesthestists within surgical areas of seventeen hospitals of the Republic of Ireland and Northern Ireland.

Results

Completed questionnaires were returned from 154 participants in Phase 1 involving all four professions of the participant cohort. This comprised of one hundred and seventeen nurses, seven midwives, ten surgeons and nineteen anaesthetists. Sudden Adult/Arrhythmic Death syndrome (SADs) was heard of by 91% of participants, and 54% have heard of ICA. The majority of participants were not at all confident or only slightly confident (48% and 32%) in caring for patients with an ICA. Eighty-four percent were not aware (61.7%) or not sure if they were aware (22.7%) of the drugs to avoid in ICA conditions such as Long QT and Brugada syndrome. Those aware (11%) of drugs to avoid were seven anaethetists, two midwives and eight nurses. Of the ten surgeons, none were aware of the drugs to avoid. When all participants were asked how relevant is knowledge of ICA to your current role 5.8% said it was not at all relevant, 29.2% said it was slightly relevant, 31.8% moderately relevant and 28.6% extremely relevant. Ninety-five percent (95%) of participants would like further education about these conditions delivered mainly by online sessions and face to face workshop methods.

Conclusions

There is limited knowledge of and confidence in caring for people with Inherited Cardiac Arrhythmias in surgical areas of the hospitals surveyed. Education is required in relation to awareness and identification of people with these conditions, signs and symptoms, unmasking and triggering a cardiac event and what medications need to be avoided. Patients may not be aware they have an Inherited Cardiac Arrhythmia, so healthcare professionals' awareness is crucial with the ability to recognise and respond appropriately to a possible cardiac event. There is a need to address these gaps as these have potential serious implications for people with an ICA during their perioperative journey.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Cormac Trust

Urinary Large Cell Neuroendocrine Carcinoma: A Clinicopathologic Analysis of 22 Cases

Large cell neuroendocrine carcinoma (LCNEC) of the urinary tract is a rare disease. We present a relatively large retrospective cohort of urinary LCNEC, 20 from the urinary bladder, and 2 from the ureter, from a single institution. The patients included 16 men and 6 women with a median age of 74.5 years. Most LCNEC presented at an advanced stage with tumors invading the muscularis propria and beyond (21/22). Eight cases were pure LCNEC, while 14 cases were mixed with other histologic types, including conventional urothelial carcinoma (n=9), carcinoma in situ (n=7), small cell carcinoma (n=6), and urothelial carcinoma with glandular (n=3) features. Most LCNEC expressed neuroendocrine markers synaptophysin (22/22), chromogranin (13/16), CD56 (7/7), TTF1 (8/8), and INSM1 (2/3). They were negative for common urothelial markers including HMWCK (0/3), p40/p63 (0/6), CK20 (0/10), and had variable GATA3 staining (4/8). Ki-67 stained 25% to nearly 100% tumor cell nuclei. Patient survival was associated with cancer stage, and pure LCNEC showed worse survival than mixed LCNEC. Compared with small cell carcinoma at similar stages from a prior study, LCNEC had a worse prognosis only when patients developed metastatic disease. For organ-confined LCNEC, neoadjuvant chemotherapy followed by radical resection is the treatment option to achieve long-term survival.

Sex- and age-related differences in the distribution of bladder cancer metastases

OBJECTIVE

Our objective was to investigate age- and sex-related differences in the distribution of metastases in patients with metastatic bladder cancer.

METHODS

Within the National Inpatient Sample database (2008-2015), we identified 7040 patients with metastatic bladder cancer. Trend test and Chi-square test analyses were used to evaluate the relationship between age and site of metastases, according to sex.

RESULTS

Of 7040 patients with metastatic bladder cancer, 5226 (74.2%) were men and 1814 (25.8%) were women. Thoracic, abdominal, bone and brain metastases were present in 19.5 vs. 23.0%, 43.6 vs. 46.9%, 23.9 vs. 18.7% and 2.4 vs. 2.9% of men vs. women, respectively. Bone was the most common metastatic site in men (23.9%) vs. lung in women (22.4%). Increasing age was associated with decreasing rates of abdominal (from 44.9 to 40.2%) and brain (from 3.2 to 1.4%) metastases in men vs. decreasing rates of bone (from 21.0 to 13.3%) and brain (from 5.1 to 2.0%) metastases in women (all P < 0.05). Finally, rates of metastases in multiple organs also decreased with age, in both men and women.

CONCLUSIONS

The distribution of metastases in bladder cancer varies according to sex. Moreover, differences exist according to patient age and these differences are also sex-specific. In consequence, patient age and sex should be considered in the interpretation of imaging, especially when findings are indeterminate.

Commentary on MJM Focus (Vol. 1, No. 2): Surgery for Temporal Lobe Epilepsy

N/A

Real world experience with heart failure risk status generated by cardiac resynchronisation therapy defibrillators: high heart failure risk status incidence, causes and timing of remote transmissions

Background

Proactive patient monitoring is of paramount importance in effective management of heart failure (HF) patients. Cardiac implantable electronic devices (CIEDs) used in HF patients are able to derive long-term trends in physiologic parameters and provide timely warning to clinicians. Little is known, however, on the real-world experience with device-generated HF risk-stratifying algorithms.

Purpose

Heart Failure Risk Score (HFRS) takes into account nine parameters and is calculated automatically based on long-term clinical trends. Remote transmissions provide information on the risk of HF event in next 30 days categorized as low, medium or high based on a maximum daily risk status in prior 30 days. We aimed to evaluate the ability of HFRS to alert HF specialists on the actual HF risk status.

Methods

The prospective registry included all patients with CIEDs featuring integrated Heart Failure Risk Score (HFRS) followed via Medtronic CareLink remote monitoring system and enabled for Co-management (CM) from May 2015 to August 2019 in a tertiary centre. High HFRS does not trigger automatic alert transmission. Study follow-up spanned between start of CM and last transmission in 2019. Inclusion criteria were CRT-D in situ, active Home Monitor, switched on OptiVol 2.0 remote alert and transmission data available on CareLink following study period completion. Transmissions were scheduled 3-monthly.

Results

Out of 229 consecutive patients, 132 met study criteria. Mean age was 74±10 years, 18% were female. Median follow-up duration was 2.7 years (IQR 1.3). Total number of transmissions was 2652, median per patient was 18 (IQR 13); scheduled, unscheduled and care alerts constituted 42%, 44% and 14%, respectively. One third of transmissions were automatically sent for CM review. There were 398 high HFRS episodes. OptiVol fluid index was below the threshold throughout 128 (32%) episodes. Missed episodes (not transmitted within 30 days from the final day of high HFRS) amounted to 130 (33%) and the reasons behind this included OptiVol alerting before the first day of high HFRS or persistently elevated when HFRS changed from low/medium to high (52%), low OptiVol index during the episode (38%) or other (10%). Median duration of high HFRS was 7 days (IQR 12, range, 1–187). Among timely picked-up high HFRS episodes, 38% were transmitted during the relevant episode and 62% afterwards with median delay of 10 days (IQR 15) from the last day of high HFRS; 21% of transmissions showing high HFRS were not highlighted for CM review which correlated with low OptiVol index, P&lt;0.001. The factors contributing to high HFRS included: raised OptiVol (60%), patient activity (83%), AT/AF (46%), ventricular rate (VR) during AF (6%), % of VP (40%), shocks (2%), treated VT/VF (2%), night VR (72%) and HR variability (34%).

Conclusions

In a real-world clinical setting high HFRS was frequently under-reported. The investigation into clinical implications is warranted.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Our department has benefited from unrestricted grants from Boston Scientific and Medtronic Inc during the last 5 years.

Racial differences in the distribution of bladder cancer metastases: a population-based analysis

INTRODUCTION

Bladder cancer is the second most common genitourinary malignancy in the United States. The incidence of bladder cancer rises with age, and it is two times more common in Caucasians than in African-Americans (23.1 vs. 12.6 cases/100,000 persons). We aimed to investigate the racial and age-related differences in the distribution of metastasis in a large, contemporary cohort of metastatic bladder cancer patients.

MATERIAL AND METHODS

Within the National Inpatient Sample database (2008-2015) we identified 5,767 patients with metastatic bladder cancer. Trend test, Chi-square test and multivariable logistic regression models were used to evaluate the relationship between ethnicity, age, and site of metastasis.

RESULTS

Of 5,767 patients with metastatic bladder cancer, 598 (10.4%) were African-American. Lung was the most common metastatic site in African-Americans (28.6%) vs. bone in Caucasians (21.7%). Overall, African-Americans showed higher rates of lung (+10.2%), liver (+7.5%) and bone (+5.2%) metastases, compared to Caucasians (all p <0.01). Brain metastases were rare in both ethnicities (3.3 vs. 2.4%; p = 0.2). Rates of exclusive bone, lung or liver metastases increased with age, but were higher in African-Americans, regardless of age strata. In the multivariable logistic regression models, African-American ethnicity independently predicted higher risk of lung (Odds ratio: 1.69), liver (odds ratio: 1.50) and bone (odds ratio: 1.27) metastases, relative to Caucasians. Moreover, a dose-response effect was found after combining the three main risk factors for developing bone metastases, namely African-American ethnicity, younger age and male gender.

CONCLUSIONS

Racial differences exist in the distribution of metastatic bladder cancer metastasis. Moreover, based on higher risk of bone metastases in African-American patients, bone imaging may be warranted in this patient population, especially in the presence of other risk factors for bone metastases, namely male gender or younger age.

Evaluation of a marker-less, intra-operative, augmented reality guidance system for robot-assisted laparoscopic radical prostatectomy

PURPOSE

Robot-assisted laparoscopic radical prostatectomy (RALRP) using the da Vinci surgical robot is a common treatment for organ-confined prostate cancer. Augmented reality (AR) can help during RALRP by showing the surgeon the location of anatomical structures and tumors from preoperative imaging. Previously, we proposed hand-eye and camera intrinsic matrix estimation procedures that can be carried out with conventional instruments within the patient during surgery, take < 3 min to perform, and fit seamlessly in the existing surgical workflow. In this paper, we describe and evaluate a complete AR guidance system for RALRP and quantify its accuracy.

METHODS

Our AR system requires three transformations: the transrectal ultrasound (TRUS) to da Vinci transformation, the camera intrinsic matrix, and the hand-eye transformation. For evaluation, a 3D-printed cross-wire was visualized in TRUS and stereo endoscope in a water bath. Manually triangulated cross-wire points from stereo images were used as ground truth to evaluate overall TRE between these points and points transformed from TRUS to camera.

RESULTS

After transforming the ground-truth points from the TRUS to the camera coordinate frame, the mean target registration error (TRE) (SD) was [Formula: see text] mm. The mean TREs (SD) in the x-, y-, and z-directions are [Formula: see text] mm, [Formula: see text] mm, and [Formula: see text] mm, respectively.

CONCLUSIONS

We describe and evaluate a complete AR guidance system for RALRP which can augment preoperative data to endoscope camera image, after a deformable magnetic resonance image to TRUS registration step. The streamlined procedures with current surgical workflow and low TRE demonstrate the compatibility and readiness of the system for clinical translation. A detailed sensitivity study remains part of future work.

Multiple instance learning combined with label invariant synthetic data for guiding systematic prostate biopsy: a feasibility study

PURPOSE

Ultrasound imaging is routinely used in prostate biopsy, which involves obtaining prostate tissue samples using a systematic, yet, non-targeted approach. This approach is blinded to individual patient intraprostatic pathology, and unfortunately, has a high rate of false negatives.

METHODS

In this paper, we propose a deep network for improved detection of prostate cancer in systematic biopsy. We address several challenges associated with training such network: (1) Statistical labels: Since biopsy core's pathology report only represents a statistical distribution of cancer within the core, we use multiple instance learning (MIL) networks to enable learning from ultrasound image regions associated with those data; (2) Limited labels: The number of biopsy cores are limited to at most 12 per patient. As a result, the number of samples available for training a deep network is limited. We alleviate this issue by effectively combining Independent Conditional Variational Auto Encoders (ICVAE) with MIL. We train ICVAE to learn label-invariant features of RF data, which is subsequently used to generate synthetic data for improved training of the MIL network.

RESULTS

Our in vivo study includes data from 339 prostate biopsy cores of 70 patients. We achieve an area under the curve, sensitivity, specificity, and balanced accuracy of 0.68, 0.77, 0.55 and 0.66, respectively.

CONCLUSION

The proposed approach is generic and can be applied to several other scenarios where unlabeled data and noisy labels in training samples are present.

Transurethral Resection of Bladder Tumour: The Neglected Procedure in the Technology Race in Bladder Cancer

Transurethral resection of bladder tumour is the initial, most critical step in the management of bladder cancer; as such, this is a call to arms for the urological community to it the due diligence it deserves regarding technology and training.

Clinical and pathological characteristics of bladder cancer in post brachytherapy patients

The long-term risk of secondary malignancy is a potential late effect of brachytherapy. However, the time interval, anatomic site and histopathology are not well studied. We sought to characterize the bladder cancers that developed following treatment of prostate cancer with brachytherapy. Between 1998 and 2014, 4570 patients were treated with brachytherapy at the BC Cancer Agency. Out of those, 69 patients subsequently developed bladder cancer, some of which could have been radiation induced. Histology slides were reviewed for all cases, and site and pathologic features were recorded. Cases were classified as luminal and basal subtypes based on GATA3 and CK5/6 immunohistochemistry. Bladder neck and trigone were among the common sites of involvement. Pathologic review of cases showed that 68 % were high-grade, 25 % were muscle-invasive, and 20 % showed variant histology, including small cell carcinoma, sarcomatoid carcinoma, squamous cell carcinoma, and adenocarcinoma. A subgroup of cases more likely to be radiation-induced, based on site and time interval, was associated with increased pathologic stage (pT1 or higher) compared to the other cases (70 % vs 34 %, p = 0.01). In conclusion, the majority of bladder cancers following brachytherapy in this cohort were of high grade and low stage at diagnosis, most of them demonstrating luminal immunophenotype. A significant number of variant histologies are seen, each demonstrating a specific immunophenotype.

Clinical and Bacterial Risk Factors for Development of Post-Prostate Biopsy Infections

PURPOSE

To research on clinical and bacterial risk factors and their relationship with post-prostate biopsy infection (PBI).

MATERIALS AND METHODS

In this prospective cohort study, rectal swabs were collected from 158 men prior to prostate biopsy and cultured selectively for identify ciprofloxacin-resistant (FQ-R) gram-negative bacteria. The patient characteristics, phylogenetic background, sequence typing and pulsed field gel electrophoresis (PFGE) pattern were compared in two groups of FQ-R E. coli rectal and clinical isolates.

RESULTS

In total, PBI was observed in 20 (12.5%) cases; the most of these subjects were FQ-R-colonized. (17/73 [24%] vs 3/85 [3.5%]; P < 0.001). FQ-R colonization, diabetes, hospitalization and UTI were independent risk factors (95% CI: 1.1-20.1, OR = 4.73; 95% CI: 1.7-25.3, OR = 6.57; 95% CI: 1.9-27.5, OR = 7.22; and 95% CI: 1.2-14.3, OR = 4.05; respectively),  that increased the rate of PBI (All P < 0.05). Despite the increase in infections among patients colonized with strains of E. coli ST131, its prevalence was near significance between colonized and infected groups (P = 0.07). The PFGE patterns and antimicrobial susceptibility profiles of rectal and clinical isolates in 13 patients were similar which is remarkably important and informative.

CONCLUSIONS

The most PBIs originate from FQ-R E. coli rectal colonization. Rectal culture screening and assessment of clinical risk factors can predict the incidence of PBI in patients.

Do Not Learn a Technique, Learn the Biology Underlying the Disease: Techniques Evolve, Biology Prevails

The evidence available suggests that open and robot-assisted radical cystectomy lead to similar outcomes in bladder cancer. True advances will come from a better understanding of the biology of the disease, and a comprehensive, multimodal approach that aims to improve patient survival and quality of life is more critical than the surgical technique.