Exploring the Language Used to Describe Older Patients at Multidisciplinary Cancer Conferences

Older adults with cancer often present with distinct complexities that complicate their care, yet the language used to discuss their management at multidisciplinary cancer conferences (MCCs) remains poorly understood. A mixed methods study was conducted at a tertiary cancer centre in Toronto, Canada, where MCCs spanning five tumour sites were attended over six months. For presentations pertaining to a patient aged 75 or older, a standardized data collection form was used to record their demographic, cancer-related, and non-cancer-related information, as well as the presenter's specialty and training level. Descriptive statistics and thematic analysis were employed to explore MCC depictions of older patients (n = 75). Frailty status was explicitly mentioned in 20.0% of presentations, but discussions more frequently referenced comorbidity burden (50.7%), age (33.3%), and projected treatment tolerance (30.7%) as surrogate measures. None of the presentations included mentions of formal geriatric assessment (GA) or validated frailty tools; instead, presenters tended to feature select GA domains and subjective descriptions of appearance ("looks to be fit") or overall health ("relatively healthy"). In general, MCCs appeared to rely on age-focused language that may perpetuate ageism. Further work is needed to investigate how frailty and geriatric considerations can be objectively incorporated into discussions in geriatric oncology.

MRI-guided Focused Ultrasound Focal Therapy for Intermediate-Risk Prostate Cancer: Final Results from a 2-year Phase II Clinical Trial

Background MRI-guided focal therapy (FT) allows for accurate targeting of localized clinically significant prostate cancer (csPCa) while preserving healthy prostate tissue, but the long-term outcomes of this approach require more study. Purpose To assess the 2-year oncological and functional outcomes of men with intermediate-risk prostate cancer (PCa) treated with targeted FT. Materials and Methods In this single-center prospective phase II trial, men with localized unifocal intermediate-risk PCa underwent transrectal MRI-guided focused ultrasound between July 2016 and July 2019. Planned ablation volumes included 10-mm margins when possible. Data regarding adverse events were collected and quality-of-life questionnaires were completed by participants at 6 weeks and at 5, 12, 18, and 24 months after treatment. Multiparametric MRI and targeted and systematic biopsies were performed at 24 months. Ablation volumes were determined by manual contouring of nonperfused volumes on immediate contrast-enhanced images. Generalized estimating equations were used to model trends in quality-of-life measures. Results Treatment was successfully completed in the 44 participants (median age, 67 years; IQR, 62-70 years; 36 patients with grade group [GG] 2; eight patients with GG 3). No major adverse events from treatment were recorded. One participant refused biopsy at 24 months. After 2 years, 39 of 43 participants (91%) had no csPCa at the treatment site and 36 of 43 (84%) had no cancer in the entire gland. No changes in International Index of Erectile Function-15 score or International Prostate Symptom Score were observed during 2-year follow-up (P = .73 and .39, respectively). Conclusion The majority of men treated with MRI-guided focused ultrasound for intermediate risk PCa had negative results for csPCa at biopsy 2 years after treatment. Additionally, there was no significant decline in quality of life per the validated questionnaires. Clinical trial registration no. NCT02968784 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Woodrum in this issue.

A Systematic Review and Meta-Analysis of the Cancer

OBJECTIVE

Prostate cancer is the second- leading cause of cancer death among men. We aimed to evaluate high-intensity focused ultrasound (HIFU), open radical prostatectomy (ORP), robot-assisted radical prostatectomy (RARP), and external beam radiation therapy (RT) in the treatment of localized low- and intermediate-risk prostate cancer.

METHODS

We searched bibliographic databases for case-control, cohort, and randomized controlled studies. We used MeSH subject headings and free text terms for prostate cancer, HIFU, ORP, RARP, RT, failure-free survival (FFS), biochemical disease-free survival (BDFS), urinary incontinence (UI), and erectile dysfunction (ED).

RESULTS

Fourteen studies were included in the review, for a total of 34 927 participants. Among the 8 studies of HIFU as the primary treatment of localized low- and intermediate- risk prostate cancer, 4 studies reported 5-year FFS rates ranging from 67.8% to 97.8%, 3 studies reported 5-year BDFS ranging from 58% to 85.4%, 5 studies reported 1-year UI rates ranging from 0% to 6%, and 4 studies reported 1-year ED rates ranging from 11.4% to 38.7%. Furthermore, our search revealed a 5-year FFS benefit favoring ORP compared to RT, a 1-year UI rate favoring ORP compared to RARP, and a 1-year ED rate favoring ORP compared to RARP.

CONCLUSION

Our systematic review and meta-analysis revealed lack of studies with active comparators comparing HIFU to standard of care (ORP, RARP, or RT) in primary treatment of localized low- and intermediate-risk prostate cancer. Open radical prostatectomy has favorable efficacy outcomes compared to RT, while RARP has beneficial functional outcomes compared to ORP, respectively.

Surgical Site Infections During the Pandemic: The Impact of the "COVID Bundle"

BACKGROUND

A reduction in surgical site infections (SSIs) has been reported in several discrete patient populations during the COVID-19 pandemic. Herein, this study evaluates the impact of the COVID-19 pandemic on SSI in a large patient cohort incorporating multiple surgical disciplines. We hypothesize that enhanced infection control and heightened awareness of such measures is analogous to an SSI care bundle, the hypothetical "COVID bundle", and may impact SSI rates.

METHOD

Data collected for the American College of Surgeons National Surgical Quality Improvement Program between January 1, 2015, and April 1, 2021, were retrospectively analyzed. SSI rates were compared among time-dependent patient cohorts: Cohort A (pre-pandemic, N = 24,060, 87%) and Cohort B (pandemic, N = 3698, 13%). Time series and multivariable analyses predicted pre-pandemic and pandemic SSI trends and tested for association with timing of surgery.

RESULTS

The overall SSI incidence was reduced in Cohort B versus Cohort A (2.8% vs. 4.5%, p < 0.001). Multivariable analysis indicated a downward SSI trend before pandemic onset (IRR 0.997, 95% CI 0.994, 1). At pandemic onset, the trend reduced by a relative factor of 39% (IRR 0.601, 95% CI 0.338, 1.069). SSI then trended upward during the pandemic (IRR 1.035, 95% CI 0.965, 1.111). SSI rates significantly trended downward in general surgical patients at pandemic onset (IRR 0.572, 95% CI 0.353, 0.928).

CONCLUSION

Although overall SSI incidence was reduced during the pandemic, a statistically significant decrease in the predicted SSI rate only occurred in general surgical patients at pandemic onset. This trend may suggest a positive impact of the "COVID bundle" on SSI rates in these patients.

Impact of 18F-DCFPyL PET/MRI in Selecting Men With Low-/Intermediate-Risk Prostate Cancer for Focal Ablative Therapies

PURPOSE

To compare the diagnostic performance of multiparametric (mp) MRI to 18F-DCFPyL PET/MRI for detecting clinically significant (cs) prostate cancer (PCa) in men with low-/intermediate-risk PCa being considered for focal ablative therapy (FT), using 2 interpretation schemes, and to assess the rate of exclusion from FT for each modality.

METHODS

This prospective study evaluated men with low- or intermediate-risk PCa, potential candidates for FT based on initial biopsy as per institutional protocol, who underwent 18F-DCFPyL PET/MRI. Each modality (mpMRI, PET/MRI using PROMISE classification [PET/MRI PROMISE], and PET/MRI considering any focal lesion on PET as positive [PETFL/MRI]) was assessed independently. All suspicious lesions underwent PET/MRI-ultrasound fusion biopsies. Diagnostic performances were calculated and compared using the exact binomial test on paired proportions.

RESULTS

Thirty-four men (median age, 64 years; interquartile range, 60-70 years) were included. Overall, 40 of 67 lesions (60%) identified on mpMRI and/or PET/MRI were malignant, and 34 of 40 lesions (85%) were csPCa (≥6 mm ISUP [International Society of Urological Pathology Grade Group] GG1 or ISUP-GG ≥2). On lesion-level analysis, for detecting csPCa, sensitivity appeared higher for PETFL/MRI than mpMRI and PET/MRI PROMISE (97% vs 76% and 79%, respectively [P = 0.02 and 0.03]), whereas specificity was lower (30% vs 85% and 88%, respectively [P < 0.001]). The calculated overall accuracy rates for PETFL/MRI, mpMRI, and PET/MRI PROMISE were 64%, 81%, and 84%, respectively. PETFL/MRI, mpMRI, and PET/MRI PROMISE excluded 10 of 34 (29%), 7 of 34 (21%), and 6 of 34 (18%) men from FT, respectively.

CONCLUSIONS

18F-DCFPyL PET/MRI excluded nearly 30% of patients with low-/intermediate-risk PCa from FT, with a potential role in decreasing selection failure. Compared with mpMRI, PET/MRI had a higher sensitivity for detecting csPCa in men who were candidates for FT.ClinicalTrials.gov identifier NCT03149861.

The impact of the early COVID-19 pandemic on healthcare system resource use and costs in two provinces in Canada: An interrupted time series analysis

INTRODUCTION

The aim of our study was to assess the initial impact of COVID-19 on total publicly-funded direct healthcare costs and health services use in two Canadian provinces, Ontario and British Columbia (BC).

METHODS

This retrospective repeated cross-sectional study used population-based administrative datasets, linked within each province, from January 1, 2018 to December 27, 2020. Interrupted time series analysis was used to estimate changes in the level and trends of weekly resource use and costs, with March 16-22, 2020 as the first pandemic week. Also, in each week of 2020, we identified cases with their first positive SARS-CoV-2 test and estimated their healthcare costs until death or December 27, 2020.

RESULTS

The resources with the largest level declines (95% confidence interval) in use in the first pandemic week compared to the previous week were physician services [Ontario: -43% (-49%,-37%); BC: -24% (-30%,-19%) (both p<0.001)] and emergency department visits [Ontario: -41% (-47%,-35%); BC: -29% (-35%,-23%) (both p<0.001)]. Hospital admissions declined by 27% (-32%,-23%) in Ontario and 21% (-26%,-16%) in BC (both p<0.001). Resource use subsequently rose but did not return to pre-pandemic levels. Only home care and dialysis clinic visits did not significantly decrease compared to pre-pandemic. Costs for COVID-19 cases represented 1.3% and 0.7% of total direct healthcare costs in 2020 in Ontario and BC, respectively.

CONCLUSIONS

Reduced utilization of healthcare services in the overall population outweighed utilization by COVID-19 patients in 2020. Meeting the needs of all patients across all services is essential to maintain resilient healthcare systems.

Development, multi-institutional external validation, and algorithmic audit of an artificial intelligence-based Side-specific Extra-Prostatic Extension Risk Assessment tool (SEPERA) for patients undergoing radical prostatectomy: a retrospective cohort study

BACKGROUND

Accurate prediction of side-specific extraprostatic extension (ssEPE) is essential for performing nerve-sparing surgery to mitigate treatment-related side-effects such as impotence and incontinence in patients with localised prostate cancer. Artificial intelligence (AI) might provide robust and personalised ssEPE predictions to better inform nerve-sparing strategy during radical prostatectomy. We aimed to develop, externally validate, and perform an algorithmic audit of an AI-based Side-specific Extra-Prostatic Extension Risk Assessment tool (SEPERA).

METHODS

Each prostatic lobe was treated as an individual case such that each patient contributed two cases to the overall cohort. SEPERA was trained on 1022 cases from a community hospital network (Trillium Health Partners; Mississauga, ON, Canada) between 2010 and 2020. Subsequently, SEPERA was externally validated on 3914 cases across three academic centres: Princess Margaret Cancer Centre (Toronto, ON, Canada) from 2008 to 2020; L'Institut Mutualiste Montsouris (Paris, France) from 2010 to 2020; and Jules Bordet Institute (Brussels, Belgium) from 2015 to 2020. Model performance was characterised by area under the receiver operating characteristic curve (AUROC), area under the precision recall curve (AUPRC), calibration, and net benefit. SEPERA was compared against contemporary nomograms (ie, Sayyid nomogram, Soeterik nomogram [non-MRI and MRI]), as well as a separate logistic regression model using the same variables included in SEPERA. An algorithmic audit was performed to assess model bias and identify common patient characteristics among predictive errors.

FINDINGS

Overall, 2468 patients comprising 4936 cases (ie, prostatic lobes) were included in this study. SEPERA was well calibrated and had the best performance across all validation cohorts (pooled AUROC of 0·77 [95% CI 0·75-0·78] and pooled AUPRC of 0·61 [0·58-0·63]). In patients with pathological ssEPE despite benign ipsilateral biopsies, SEPERA correctly predicted ssEPE in 72 (68%) of 106 cases compared with the other models (47 [44%] in the logistic regression model, none in the Sayyid model, 13 [12%] in the Soeterik non-MRI model, and five [5%] in the Soeterik MRI model). SEPERA had higher net benefit than the other models to predict ssEPE, enabling more patients to safely undergo nerve-sparing. In the algorithmic audit, no evidence of model bias was observed, with no significant difference in AUROC when stratified by race, biopsy year, age, biopsy type (systematic only vs systematic and MRI-targeted biopsy), biopsy location (academic vs community), and D'Amico risk group. According to the audit, the most common errors were false positives, particularly for older patients with high-risk disease. No aggressive tumours (ie, grade >2 or high-risk disease) were found among false negatives.

INTERPRETATION

We demonstrated the accuracy, safety, and generalisability of using SEPERA to personalise nerve-sparing approaches during radical prostatectomy.

FUNDING

None.

The role of [18F]-DCFPyL PET/MRI radiomics for pathological grade group prediction in prostate cancer

PURPOSE

To evaluate the diagnostic accuracy of [18F]-DCFPyL PET/MRI radiomics for the prediction of pathological grade group in prostate cancer (PCa) in therapy-naïve patients.

METHODS

Patients with confirmed or suspected PCa, who underwent [18F]-DCFPyL PET/MRI (n = 105), were included in this retrospective analysis of two prospective clinical trials. Radiomic features were extracted from the segmented volumes following the image biomarker standardization initiative (IBSI) guidelines. Histopathology obtained from systematic and targeted biopsies of the PET/MRI-detected lesions was the reference standard. Histopathology patterns were dichotomized as ISUP GG 1-2 vs. ISUP GG ≥ 3 categories. Different single-modality models were defined for feature extraction, including PET- and MRI-derived radiomic features. The clinical model included age, PSA, and lesions' PROMISE classification. Single models, as well as different combinations of them, were generated to calculate their performances. A cross-validation approach was used to evaluate the internal validity of the models.

RESULTS

All radiomic models outperformed the clinical models. The best model for grade group prediction was the combination of PET + ADC + T2w radiomic features, showing sensitivity, specificity, accuracy, and AUC of 0.85, 0.83, 0.84, and 0.85, respectively. The MRI-derived (ADC + T2w) features showed sensitivity, specificity, accuracy, and AUC of 0.88, 0.78, 0.83, and 0.84, respectively. PET-derived features showed 0.83, 0.68, 0.76, and 0.79, respectively. The baseline clinical model showed 0.73, 0.44, 0.60, and 0.58, respectively. The addition of the clinical model to the best radiomic model did not improve the diagnostic performance. The performances of MRI and PET/MRI radiomic models as per the cross-validation scheme yielded an accuracy of 0.80 (AUC = 0.79), whereas clinical models presented an accuracy of 0.60 (AUC = 0.60).

CONCLUSION

The combined [18F]-DCFPyL PET/MRI radiomic model was the best-performing model and outperformed the clinical model for pathological grade group prediction, indicating a complementary value of the hybrid PET/MRI model for non-invasive risk stratification of PCa. Further prospective studies are required to confirm the reproducibility and clinical utility of this approach.

Validating the total cancer location density metric for stratifying patients with low-risk localized prostate cancer at higher risk of grade group reclassification while on active surveillance

PURPOSE

To validate a previously proposed prognostic metric, Total Cancer Location (TCLo) density, in a contemporary cohort of men with grade group (GG) 1 prostate cancer (PCa) on active surveillance (AS).

METHODS

We evaluated 123 patients who entered AS with maximum GG1 PCa at diagnostic and/or confirmatory biopsy. TCLo was defined as the total number of PCa locations identified on both biopsy sessions. TCLo density was calculated as TCLo / prostate volume [ml]. Primary endpoint was progression-free survival (PFS), defined as time from confirmatory biopsy to grade group reclassification (GGR) on repeat biopsy or prostatectomy. Optimal cut-point for TCLo density was predefined in a previously reported cohort and applied to this contemporary cohort. Kaplan-Meier and multivariable Cox regression analysis were used to estimate the association of predictors with PFS.

RESULTS

During median follow-up of 7.8 years, (IQR 7.3-8.2) 34 men had GGR. Using previously defined cut-points, PFS at 5-years was 60% (95% CI: 44%-81%) vs. 89% (95% CI: 83%-96%) in men with high (≥0.06 ml^-1) vs. low (<0.06 ml^-1) TCLo density, and 63% (95% CI: 48%-82%) vs. 90% (95% CI: 83%-96%) in men with high (≥3) vs. low (≤2) TCLo (log-rank test: P < 0.0001, respectively). Adjusting for age, prostate volume, percent of positive cores and PSA, both higher TCLo density (HR [per 0.01 ml^-1 increase]: 1.18, 95% CI: 1.05-1.33, P = 0.005) and TCLo (HR: 1.69, 95% CI: 1.20-2.38, P = 0.002) were associated with shorter PFS.

CONCLUSION

The previously suggested prognostic value of TCLo density was confirmed in this validation cohort. TCLo alone performed similarly well. Patients with high TCLo density (≥0.06 ml^-1) or TCLo (>2) were at greater risk of GGR while on AS. With external validation, these metric may help guide risk-adapted surveillance protocols.

Urinary complications after penile inversion vaginoplasty in transgender women: Systematic review and meta-analysis

Introduction: Penile inversion vaginoplasty (PIV) remains the gold standard technique for vaginoplasty, a gender-affirming feminizing surgery, but has been associated with urinary complications; however, there is little literature synthesizing urinary complications after PIV surgery, and there is a need to compile these complications to counsel patients pre- and postoperatively on managing surgical expectations. In this systematic review, we summarize the prevalence of urinary complications following PIV. Methods: We searched the MEDLINE, EMBASE, CINAHL, and Scopus databases in July 2020. The primary outcome was the prevalence of urinary and surgical complications in patients after penile inversion vaginoplasty. Pooled prevalence was determined from extrapolated data. ROBINS-I tool was used to assess study quality. The study was prospectively registered on PROSPERO (CRD42020204139). Results: Of 843 unique records, 27 articles were pooled for synthesis, with 3388 patients in total. Overall patient satisfaction ranged from 80–100%. The most common urological complications included poor/splayed stream (11.7%, 95% confidence interval [CI] 5.7–19.3), meatal stenosis (6.9%, 95% CI 2.7–12.7), and irritative symptoms (frequency, urgency, nocturia) (11.5%, 95% CI 2.6–25.1). Other urinary complications included retention requiring catheterization (5.1%, 95% CI 0.3–13.8), incontinence (8.7%, 95% CI 3.4–15.6), urethral stricture (4.6%, 95% CI 1.2–9.8), and urinary tract infection (5.6%, 95% CI 2.7–9.4). Most pooled studies had moderate risk of bias. Conclusions: The available evidence suggests that there is a low prevalence of urinary complications following PIV. Overall, there is a need for standardization of data in transgender surgical care to better understand surgical outcomes and improve postoperative management.

Comparison of Micro-US and Multiparametric MRI for Prostate Cancer Detection in Biopsy-Naive Men

Background Multiparametric MRI has led to increased detection of clinically significant prostate cancer (csPCa). Micro-US is being investigated for csPCa detection. Purpose To compare multiparametric MRI and micro-US in detecting csPCa (grade group ≥2) and to determine the proportion of MRI nodules visible at micro-US for real-time targeted biopsy. Materials and methods This prospective, single-center trial enrolled biopsy-naive men with suspected prostate cancer (PCa) between May 2019 and September 2020. All patients underwent multiparametric MRI followed by micro-US; findings at both were interpreted in a blinded fashion, followed by targeted biopsy and nontargeted systematic biopsy using micro-US. Proportions were compared using the exact McNemar test. The differences in proportions were calculated. Results Ninety-four men (median age, 61 years; IQR, 57-68 years) were included. MRI- and micro-US-targeted biopsy depicted csPCa in 37 (39%) and 33 (35%) of the 94 men, respectively (P = .22); clinically insignificant PCa in 14 (15%) and 15 (16%) (P > .99); and cribriform and/or intraductal PCa in 14 (15%) and 13 (14%) (P > .99). The MRI- plus micro-US-targeted biopsy pathway depicted csPCa in 38 of the 94 (40%) men. The addition of nontargeted systematic biopsy to MRI- plus micro-US-targeted biopsy did not enable identification of any additional men with csPCa but did help identify nine additional men with clinically insignificant PCa (P = .04). Biopsy was avoided in 32 of the 94 men (34%) with MRI and nine of the 94 men (10%) with micro-US (P < .001). Among 93 MRI targets, 62 (67%) were prospectively visible at micro-US. Conclusion MRI and micro-US showed similar rates of prostate cancer detection, but more biopsies were avoided with the MRI pathway than with micro-US, with no benefit of adding nontargeted systematic biopsy to the MRI- plus micro-US-targeted biopsy pathway. Most MRI lesions were prospectively visible at micro-US, allowing real-time targeted biopsy. ClinicalTrials.gov registration no.: NCT03938376 © RSNA, 2022 Online supplemental material is available for this article.

Prostate biopsy in the era of MRI-targeting: towards a judicious use of additional systematic biopsy

OBJECTIVES

We aimed to develop and compare strategies that help optimize current prostate biopsy practice by identifying patients who may forgo concurrent systematic biopsy (SBx) in favor of MRI-targeted (TBx) alone.

METHODS

Retrospective study on 745 patients who underwent combined MRI-TBx plus SBx. Primary outcome was the upgrade to clinically significant prostate cancer (csPCa; grade group ≥ 2) on SBx versus MRI-TBx. Variables (age, previous biopsy status, Prostate Imaging Reporting and Data System (PI-RADS) score, index lesion size/location, number of lesions, PSA, PSA density, prostate volume) associated with the primary outcome were identified by logistic regression and used for biopsy strategies. Clinical utility was assessed by decision curve analysis (DCA).

RESULTS

SBx detected 47 (6%) additional men with csPCa. The risk of detecting csPCa uniquely on SBx was significantly lower in men with PI-RADS 5 (versus PI-RADS 3: OR 0.30, p = 0.03; versus PI-RADS 4: OR 0.33, p = 0.01), and previous negative biopsy (versus previous positive biopsy: OR 0.40, p = 0.007), and increased with age (per 10 years: OR 1.64, p = 0.016). No significant association was observed for other variables. DCA identified the following strategies as most useful: (a) avoid SBx in men with PI-RADS 5 and (b) additionally in those with previous negative biopsy, resulting in avoiding SBx in 201 (27%) and 429 (58%), while missing csPCa in 5 (1%) and 15 (2%) patients, respectively.

CONCLUSION

Not all men benefit equally from the combination of SBx and MRI-TBx. SBx avoidance in men with PI-RADS 5 and/or previous negative biopsy may reduce the risk of excess biopsies with a low risk of missing csPCa.

KEY POINTS

• In men undergoing MRI-targeted biopsy, the risk of detecting clinically significant prostate cancer (csPCa) only on additional systematic biopsy (SBx) decreased in men with PI-RADS 5, previous negative biopsy, and younger age. • Using these variables may help select men who could avoid the risk of excess SBx. • If missing csPCa in 5% was acceptable, forgoing SBx in men with PI-RADS 5 and/or previous negative biopsy enabled the highest net reduction in SBx.

Extended Results and Independent Validation of a Phase 2 Trial of Metastasis Directed Therapy for Molecularly Defined Oligometastatic Prostate Cancer

PURPOSE

The role of metastasis-directed therapy (MDT) in molecularly defined oligorecurrent prostate cancer (PCa) remains irresolute. We present extended follow-up and an independent validation cohort of a prospective trial.

METHODS AND MATERIALS

This study consists of 2 sequential single-arm phase-2 trials of patients with biochemical recurrence (prostate specific antigen [PSA] 0.4-3.0 ng/mL) and negative conventional imaging after radical prostatectomy and postoperative radiation therapy. All patients underwent [¹⁸F]DCFPyL positron emission tomography/computed tomography. Patients with molecularly defined oligorecurrent prostate cancer underwent MDT with stereotactic body radiation therapy or surgery, without androgen deprivation therapy (ADT). The primary end point was biochemical response (≥50% PSA decline from baseline). Secondary end points included PSA progression-free survival and ADT-free survival. The sample size of 37 MDT patients was determined based on a Simon's 2-stage design with biochemical response rate >20%, and this design was also applied for the subsequent independent validation cohort.

RESULTS

Seventy-four patients underwent MDT: 37 each in the initial and validation cohorts. Both cohorts met the prespecified biochemical response rate and completed the planned 2-stages of accrual. For the pooled cohort, the median number of prostate specific membrane antigen positron emission tomography avid lesions was 2 and most (87%) recurrences were nodal. Sixty-four (87%) had stereotactic body radiation therapy and 10 (13%) had surgery. Median follow-up (interquartile range [IQR]) for the initial, validation and combined cohorts were 41 (35-46) months, 14 months (7-21), and 24 months (14-41), respectively. The biochemical response rates for the initial, validation and combined cohorts were 59%, 43%, and 51%, respectively. For the combined cohort, median biochemical progression-free survival was 21 months (95% confidence interval, 13-not reached), and median ADT-free survival was 45 months (95% confidence interval, 31-not reached).

CONCLUSIONS

Half of patients treated with MDT for molecularly defined-only oligorecurrent prostate cancer exhibited a biochemical response. This study provides necessary and validated evidence to support randomized trials aiming to determine whether MDT (alone or with systemic therapy) can affect clinically meaningful end points.

"Bring the Hoses to Where the Fire Is!": Differential Impacts of Marginalization and Socioeconomic Status on COVID-19 Case Counts and Healthcare Costs

OBJECTIVES

Local health leaders and the Director General of the World Health Organization alike have observed that COVID-19 "does not discriminate." Nevertheless, the disproportionate representation of people of low socioeconomic status among those infected resembles discrimination. This population-based retrospective cohort study examined COVID-19 case counts and publicly funded healthcare costs in Ontario, Canada, with a focus on marginalization.

METHODS

Individuals with their first positive severe acute respiratory syndrome coronavirus 2 test from January 1, 2020 to June 30, 2020, were linked to administrative databases and matched to negative/untested controls. Mean net (COVID-19-attributable) costs were estimated for 30 days before and after diagnosis, and differences among strata of age, sex, comorbidity, and measures of marginalization were assessed using analysis of variance tests.

RESULTS

We included 28 893 COVID-19 cases (mean age 54 years, 56% female). Most cases remained in the community (20 545, 71.1%) or in long-term care facilities (4478, 15.5%), whereas 944 (3.3%) and 2926 (10.1%) were hospitalized, with and without intensive care unit, respectively. Case counts were skewed across marginalization strata with 2 to 7 times more cases in neighborhoods with low income, high material deprivation, and highest ethnic concentration. Mean net costs after diagnosis were higher for males ($4752 vs $2520 for females) and for cases with higher comorbidity ($1394-$7751) (both P < .001) but were similar across levels of most marginalization dimensions (range $3232-$3737, all P ≥ .19).

CONCLUSIONS

This study suggests that allocating resources unequally to marginalized individuals may improve equality in outcomes. It highlights the importance of reducing risk of COVID-19 infection among marginalized individuals to reduce overall costs and increase system capacity.

Initial health care costs for COVID-19 in British Columbia and Ontario, Canada: an interprovincial population-based cohort study

BACKGROUND

COVID-19 imposed substantial health and economic burdens. Comprehensive population-based estimates of health care costs for COVID-19 are essential for planning and policy evaluation. We estimated publicly funded health care costs in 2 Canadian provinces during the pandemic's first wave.

METHODS

In this historical cohort study, we linked patients with their first positive SARS-CoV-2 test result by June 30, 2020, in 2 Canadian provinces (British Columbia and Ontario) to health care administrative databases and matched to negative or untested controls. We stratified patients by highest level of initial care: community, long-term care, hospital (without admission to the intensive care unit [ICU]) and ICU. Mean publicly funded health care costs for patients and controls, mean net (attributable to COVID-19) costs and total costs were estimated from 30 days before to 120 days after the index date, or to July 31, 2020, in 30-day periods for patients still being followed by the start of each period.

RESULTS

We identified 2465 matched people with a positive test result for SARS-CoV-2 in BC and 28 893 in Ontario. Mean age was 53.4 (standard deviation [SD] 21.8) years (BC) and 53.7 (SD 22.7) years (Ontario); 55.7% (BC) and 56.1% (Ontario) were female. Net costs in the first 30 days after the index date were $22 010 (95% confidence interval [CI] 19 512 to 24 509) and $15 750 (95% CI 15 354 to 16 147) for patients admitted to hospital, and $65 828 (95% CI 58 535 to 73 122) and $56 088 (95% CI 53 721 to 58 455) for ICU patients in BC and Ontario, respectively. In the community and long-term care settings, net costs were near 0. Total costs for all people, from 30 days before to 30 days after the index date, were $22 128 330 (BC) and $175 778 210 (Ontario).

INTERPRETATION

During the first wave, we found that mean costs attributable to COVID-19 were highest for patients with ICU admission and higher in BC than Ontario. Reducing the number of people who acquire COVID-19 and severity of illness are required to mitigate the economic impact of COVID-19.

Exploring the value of using patient-oriented MRI reports in clinical practice - a pilot study

PURPOSE

Standard radiology reports (SRR) are designed to communicate information between doctors. With many patients having instantaneous access to SRRs on patient portals, interpretation without guidance from doctors can cause anxiety and panic. In this pilot study, we designed a patient-centred prostate MRI template report (PACERR) to address some of these challenges and tested whether PACERRs improve patient knowledge and experience.

MATERIALS AND METHODS

Patients booked for clinical prostate MRI were randomly assigned to SRR or SRR + PACERR. Questionnaires included multiple-choice that targeted 4 domains (understanding, usefulness, next steps, emotional experience) hypothesized to improve with patient-centred reports and short answer questions, testing knowledge regarding MRI results. Clinical encounters were observed and recorded to explore whether adding PACERR improved communication. Likert scaled-responses and short-answer questions were compared using Mann-Whitney U test and Kruskal-Wallis test.

RESULTS

Of the 40 participants, the majority were MRI naïve (70%). Patients receiving a PACERR had higher scores in the categories of patient understanding (mean: 4.17 vs. 3.39, p=0.006), usefulness (mean: 4.58 vs. 3.07, p<0.001), and identifying next steps (mean: 1.89 vs. 3.03, p=0.003) but not emotional experience (mean: 4.18 vs. 3.79, p=0.22). PACERR participants found the layout and design more patient friendly (mean: 4.47 vs. 2.61, p<0.001) and easier to understand (mean: 4.37 vs. 2.38, p<0.001). In the knowledge section, overall, the PACERR arm scored better (87% vs. 56%, p=0.004).

CONCLUSION

With the addition of prostate MRI PACERR, participants had better understanding of their results and felt more prepared to involve themselves in discussions with their doctor.

Cystoscopic surveillance protocol for ureteral stents used to manage malignant ureteral obstruction: reducing morbidity of frequent stent changes

PURPOSE

To evaluate a cystoscopic surveillance protocol used to mitigate morbidity associated with chronic ureteral stents for malignant ureteral obstruction (MUO).

MATERIALS AND METHODS

A retrospective cohort study was conducted at a tertiary, referral centre of consecutive MUO patients who were initially managed with a ureteral stent and subsequently followed using a cystoscopic 'MUO stent surveillance protocol'. Multivariable regression models evaluated factors associated with the following outcomes: number of stent changes, time to first stent change, and overall survival.

RESULTS

A total of 120 patients from May 2009 to December 2019 were included; mean age was 63 years, majority (76.7%) were female, and median follow-up for stented patients was 184 days. Majority (72%) of patients did not require a stent change at 3-months follow-up. Only 32% (19/60) required a stent change at their 6-month stent surveillance cystoscopy. Median time to first stent change was 158 days. Of 344 total number of stent surveillance cystoscopies performed, 39.5% (136/344) involved a stent change. Patients with a history of pelvic radiation (subdistribution hazard rate [sHR] 2.12, 95% CI 1.23 to 3.67, p=0.007) and with a history of bowel resection (sHR 2.06, 95% CI 1.05 to 4.03, p=0.036) were independently associated with earlier stent changes. No patients in the MUO stent surveillance protocol required ancillary procedures to deal with encrusted stents.

CONCLUSIONS

A cystoscopic 'MUO stent surveillance protocol' can reduce the morbidity and health care expenditures associated with stent changes among MUO patients, with median time to first stent change being 158 days and only 40% of surveillance cystoscopies involving a stent change. The protocol is safe as no patients required ancillary procedures to manage an encrusted stent while on surveillance. Patients with a history of pelvic radiation or bowel resection were more likely to require a stent change during their stent surveillance visits.

Role of multiparametric MRI in long-term surveillance following focal laser ablation of prostate cancer

OBJECTIVE

Determine the multiparametric magnetic resonance imaging (mpMRI) appearance of the prostate following focal laser ablation (FLA) for PCa and to identify imaging characteristics associated with recurrent disease.

METHODS

Retrospective analysis of patients who underwent FLA for low-intermediate risk PCa between 2010 and 2014 was performed. Early (median 4 months) and late mpMRI (median 49 months) follow-up were qualitatively assessed for T₂-weighted, dynamic contrast enhanced (DCE) and diffusion weighted imaging (DWI) appearances and also compared to corresponding PSA values and biopsy results.

RESULTS

55 cancers were treated in 54 men (mean age 61.0 years). Early mpMRI was performed in 30 (54.5%) patients while late follow-up mpMRI in 42 (84%). Ill-defined scarring with and without atrophy at the treatment site were the most common appearances. In patients with paired MRI and biopsy, one of four patients with clinically significant PCa on biopsy (≥GG2 or≥6 mm GG1) showed hyperenhancement or restricted diffusion at early follow-up. At late follow-up, positive biopsies were seen in 5/8 (63%) cases with hyperenhancement and 5/6 (83%) cases with restricted diffusion at the treatment site. PSA change was not associated with biopsy results at either time point.

CONCLUSION

mpMRI is able to document the morphological and temporal changes following focal therapy. It has limited ability to detect recurrent disease in early months following treatment. Late-term mpMRI is sensitive at identifying patients with recurrent disease. Small sample size is, however, a limitation of the study.

ADVANCES IN KNOWLEDGE

Implementing MRI in follow-up after FT may be useful in predicting residual or recurrent PCa and therefore provide reliable outcome data.

Survival outcomes of metastatic renal cell carcinoma (mRCC) with sarcomatoid differentiation (SD): A single-institutional experience and literature meta-analysis

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Background: Patients (pts) with mRCC with SD have unfavorable outcomes and poor prognosis due to aggressive tumor behavior. Chemotherapy and targeted treatment are often of little benefit. However, recent studies have shown a survival benefit of immunotherapy (IO). Here, we report survival outcomes of pts with mRCC with SD treated with first line IO or chemotherapy or targeted treatment. In addition we performed a meta-analysis of recent practice changing phase III, IO trials in mRCC. Methods: This retrospective survival analysis was performed in pts with mRCC with SD treated with IO or non-IO treatment at Princess Margaret Cancer Centre (PM), Toronto. Demographics, disease characteristics and survival outcomes were collected. Progression free survival (PFS), and overall survival (OS) were calculated using the Kaplan-Meier method (log-rank). PFS and OS hazard ratios (HR) were calculated using cox proportional hazards model. We identified the major, practice changing clinical trials that reported survival outcomes of mRCC with SD treated with IO and performed a random-effects meta-analysis of HR for PFS and OS. We compared these pooled results to our single institution experience. Results: We identified 474 pts diagnosed with mRCC at PM between 2002 and 2019. In total, 44 (9.3%) pts had mRCC with SD who were treated with IO or non-IO. Of these, 29 (65.9%) pts had pure SD and 15 (34.1%) pts had mixed rhabdoid and SD features. Median age was 59.6 years (36-78) and 33 (75%) were male. Overall, as per the IMDC score, 3(6.8%), 21(47.7%) and 20(45.5%) pts were categorized as good, intermediate, and poor risk, respectively. Eight (18.2%) pts were treated with IO as first line of treatment, and 36 (81.8%) pts received non-IO. With a median follow up of 64.8 months (range, 45.7-83.8 months), the median OS for the whole mRCC with SD cohort was 15.6 months (95% CI: 8.6-22.5). The median OS in all pts treated with IO vs non-IO was not reached vs 10.3 months (95%CI: 1.49-19.1 months; p = 0.005), respectively. The HR for OS was 0.1 (95%CI: 0.01-0.78; p = 0.023) favoring IO receipt. The median PFS in all pts treated with IO vs non-IO was 24 months (95%CI: non-estimable) vs 5.4 months (95%CI: 2.9-7.8 months; p = 0.021), respectively. The HR for PFS was 0.3 (95%CI: 0.11-0.89; p = 0.03) favoring IO receipt. We identified through meta-analysis five phase III clinical trials reporting PFS and OS in pts with mRCC with SD who received IO. The overall HR for OS and PFS for the total cohort were 0.55 (95%CI: 0.41-0.74), and 0.53 (95%CI: 0.42-0.67), respectively. Conclusions: Our meta-analysis has confirmed the benefit of IO agents in mRCC with SD. While the numbers included in this retrospective review were small, they have provided real world corroboration of the trial findings. Pts with mRCC and SD benefit from IO treatment, which should be considered the standard of care for these patients.

The survival outcomes of the metastatic renal cell carcinoma with rhabdoid differentiation in immunotherapy era: Princess Margaret Cancer Center experience

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Background: Patients (pts) diagnosed with metastatic renal cell carcinoma (mRCC) with rhabdoid differentiation (RD) have a poor prognosis due to aggressive tumor behavior and inherent treatment resistance to targeted therapies. However, recent data has demonstrated the survival benefit of immunotherapy (IO) in mRCC. Here, we report survival outcomes of pts with mRCC with RD treated with targeted therapy and or IO. Methods: This retrospective survival analysis was performed in pts with mRCC and RD treated with targeted treatment and IO at Princess Margaret Cancer Centre (PM), Toronto. Demographics, disease characteristics and survival outcomes were collected. Overall survival (OS) was calculated using the Kaplan-Meier method (log-rank). OS hazard ratio (HR) were calculated using cox proportional hazards model. IBM SPSS Statistics v26 was used to conduct statistical analyses. Results: We identified 474 pts diagnosed with mRCC at PM between 2002 and 2019. A total of 57 (12%) pts diagnosed with mRCC had RD and were treated with targeted and or IO agents. Of these, 42 (73.7%) pts had pure RD and 15 (26.3%) pts had mixed RD and sarcomatoid features. Median age was 62 yrs (35-86yrs) and 42 (73.7%) were male. Overall, as per the IMDC score, 5(8.8%), 27(47.4%) and 25(43.8%) pts were categorized as good, intermediate, and poor risk, respectively. In total, 34 (59.6%) pts were treated with targeted therapy only during their first and second line treatment course and 23 (40.4%) pts received IO alone or in combination with targeted treatment in the first or second line. With a median follow up of 53.4 months (range, 38.3-68.4 months), the median OS for the whole mRCC with RD cohort was 23.1 months (95% CI: 14.6-31.5). The median OS in all pts treated with targeted therapy only vs IO receipt was 13.1 months (95%CI: 5.4-20.8 months) vs not reached; p = 0.026, respectively. HR for OS was 0.44 (95%CI: 0.22-0.93; p = 0.03) favoring IO receipt. Conclusions: While the number of pts included in our retrospective review was small, our analysis has suggested that pts with mRCC and RD have poor survival outcomes that may be improved with IO treatment. RD is a histopathological feature that could identify pts who may benefit from IO therapy. Further analysis is needed to explore the impact of RD on IO treatment response.

Prevalence of adverse pathology features in grade group 2 prostatectomy specimens with syn- or metachronous metastatic disease

BACKGROUND

To validate the importance of recently established adverse histopathology features (cribriform pattern and intraductal carcinoma) as contra-indication for deferred treatment of Gleason score 7 (3 + 4) (grade group [GG] 2) prostate cancer, we investigated their frequency in GG2 radical prostatectomies with syn- or metachronous metastatic disease.

METHODS

GG2 prostatectomy specimens of patients with concomitant lymph node metastasis or distant metastasis at follow-up were identified in a clinical database of a tertiary care center and their pathology was reviewed for pathological stage, lymphovascular invasion, Gleason grade 4 subpatterns, presence of tertiary grade 5, and ductal adenocarcinoma histology. A control group of 99 GG2 prostatectomy specimens who had no metastatic disease (controls) was reviewed for the same adverse pathological features.

RESULTS

Of 1860 GG2 prostatectomy specimens (operated between 2002 and 2020), 45 (2.4%) had concurrent regional lymph node metastases or distant metastases at follow-up. Pathological stage distribution of cases and controls was 24% and 79% pT2, 42% and 15% pT3a, 33% and 6.1% pT3b -T4, respectively (p < 0.001). Eleven of 45 cases (24%) had ≤10% Gleason grade 4 component. Cribriform pattern or intraductal carcinoma was present in 84% of cases versus 34% of controls (p < 0.001), tertiary grade 5 in 16% of cases versus 5% controls (p = 0.05) and ductal adenocarcinoma in 16% of cases versus 2% of controls (p = 0.004). Among the seven cases without cribriform or intraductal carcinoma, two displayed ductal adenocarcinoma features.

CONCLUSIONS

Well-established unfavorable histopathologic features (intraductal and cribriform pattern carcinoma, ductal adenocarcinoma) are represented in about 90% of GG2 prostate cancers with local or distant metastatic disease and are much less common (38%) in those without metastatic disease. Strikingly, about 25% of GG2 prostatectomy cases with metastatic disease had an organ-confined disease and/or a small percentage of Gleason grade 4 pattern. This further emphasizes the relative importance of these adverse histopathological features (cribriform, intraductal, and ductal adenocarcinoma) rather than percentage Gleason grade 4 as contra-indicator of deferred treatment for patients with GG2 prostate cancer.

Salvage lymph node dissection for prostate-specific membrane antigen (PSMA) positron emission tomography (PET)-identified oligometastatic disease

INTRODUCTION

The availability of prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) imaging, particularly in the setting of rising prostate-specific antigen (PSA) after definitive treatment, has led to oligometastatic prostate cancer being increasingly identified. Despite the enthusiasm surrounding treating oligometastatic disease, it has been relatively understudied. We sought to review our salvage lymphadenectomy experience in the PSMA PET/CT era.

METHODS

We retrospectively reviewed patients undergoing lymphadenectomy following curative-intent primary therapy with rising PSA who had undergone a PSMA PET/CT identifying oligometastatic disease (defined as ≤5 PSMA-avid lesions) between January 2016 and April 2020. The primary endpoint was complete response, defined as achieving a PSA <0.2 ng/ml without concomitant androgen deprivation therapy (ADT).

RESULTS

Twenty-two patients were included. Primary curative therapy included radical prostatectomy (86.4%) and brachytherapy (13.6%). Median PSA at salvage surgery was 1.72 ng/ml. Pelvic lymph node dissection was the most performed procedure (72.7%). Median node yield was 10.5, with a median of 1.5 positive nodes on pathology. Eight patients (36.4%) achieved PSA <0.2, with six (27.3%) remaining with PSA <0.2 after a median followup of 23.1 months. Nine (40.9%) had an initial PSA decline, but nadired ≥0.2, and in five (22.7%) the PSA rose immediately after surgery. Overall, ADT was started in seven patients (31.8%) at a median of 10.1 months post-salvage surgery.

CONCLUSIONS

In our series of salvage dissection for PSMA-PET-detected nodal oligometastases, approximately a third achieved PSA <0.2; yet, it was only durable in 27%. Prospective trials of salvage nodal radiation are ongoing, however, more prospective trials of salvage node dissection are needed.

Multiparametric Magnetic Resonance Imaging in the Diagnosis of Clinically Significant Prostate Cancer: an Updated Systematic Review

There has been growing utilisation of multiparametric magnetic resonance imaging (MPMRI) as a non-invasive tool to diagnose and localise clinically significant prostate cancer (CSPCa). This updated systematic review examines the use of MPMRI in patients with an elevated risk of CSPCa who have had a prior negative transrectal ultrasound systematic biopsy (TRUS-SB) and who were biopsy naïve. MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews were searched for existing systematic reviews published up to September 2020. The literature search of the electronic databases combined disease-specific terms (prostate cancer, prostate carcinoma, etc.) and treatment-specific terms (magnetic resonance, etc.). Studies were included if they were randomised controlled trials (RCTs) comparing MPMRI to template transperineal mapping biopsy (TPMB) or to TRUS-SB. Thirty-six RCTs were eligible. For biopsy-naïve men, accuracy of diagnosis of CSPCa showed sensitivities from 87 to 96% and specificities ranging from 29 to 45%. Meta-analyses for CSPCa showed increased detection favouring MPMRI-targeted biopsy over TRUS-SB by 3% (95% confidence interval 0-7%, P = 0.03) and decreased detection of clinically insignificant prostate cancer (CISPCa) favouring MPMRI by 8% (95% confidence interval -11 to 5%, P < 0.00001). Accuracy of MPMRI for men with prior negative biopsy showed sensitivities of 78-100% and specificities of 30-100%. Meta-analyses comparing MPMRI to TRUS-SB showed increased detection of 5% (95% confidence interval 3-7%, P < 0.0001) with a reduction of CISPCa detection of 7% (95% confidence interval 4-9%, P < 0.00001). The growing acceptance of MPMRI utilisation internationally and the recent publication of several RCTs regarding MPMRI in reducing CISPCa detection rates, particularly in biopsy-naïve men, without loss of sensitivity for CSPCa necessitates the synthesis of updated evidence examining MPMRI in the diagnosis of CSPCa.

Avoiding Unnecessary Biopsy: MRI-based Risk Models versus a PI-RADS and PSA Density Strategy for Clinically Significant Prostate Cancer

Background In validation studies, risk models for clinically significant prostate cancer (csPCa; Gleason score ≥3+4) combining multiparametric MRI and clinical factors have demonstrated poor calibration (over- and underprediction) and limited use in avoiding unnecessary prostate biopsies. Purpose MRI-based risk models following local recalibration were compared with a strategy that combined Prostate Imaging Data and Reporting System (PI-RADS; version 2) and prostate-specific antigen density (PSAd) to assess the potential reduction of unnecessary prostate biopsies. Materials and Methods This retrospective study included 385 patients without prostate cancer diagnosis who underwent multipara-metric MRI (PI-RADS category ≥3) and MRI-targeted biopsy between 2015 and 2019. Recalibration and selection of the best-performing MRI model (MRI-European Randomized Study of Screening for Prostate Cancer [ERSPC], van Leeuwen, Radtke, and Mehralivand models) were undertaken in cohort C1 (n = 242; 2015-2017). The impact on biopsy decisions was compared with an alternative strategy (no biopsy for PI-RADS category 3 plus PSAd < 0.1 ng/mL per milliliter) in cohort C2 (n = 143; 2018-2019). Discrimination, calibration, and clinical utility were assessed by using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis, respectively. Results The prevalence of csPCa was 38% (93 of 242 patients) and 45% (64 of 143 patients) in cohorts C1 and C2, respectively. Decision curve analysis demonstrated the highest net benefit for the van Leeuwen and Mehralivand models in C1. Used for biopsy decisions in C2, van Leeuwen (AUC, 0.84; 95% CI: 0.77, 0.9) and Mehralivand (AUC, 0.79; 95% CI: 0.72, 0.86) enabled no net benefit at a risk threshold of 10%. Up to a risk threshold of 15%, net benefit remained inferior to the PI-RADS plus PSAd strategy, which avoided biopsy in 63 per 1000 men, without missing csPCa. Without prior recalibration in C1, three of four models (MRIERSPC, Radtke, Mehralivand) were poorly calibrated and not clinically useful in C2. Conclusion The number of unnecessary prostate biopsies in men with positive MRI may be safely reduced by using a prostate-specific antigen density-based strategy. In a risk-averse scenario, this strategy enabled better biopsy decisions compared with MRI-based risk models. ©RSNA, 2021 Online supplemental material is available for this article.

Attitude is everything: keep probe pitch neutral during side-fire prostate biopsy. A simulator study

OBJECTIVES

To develop and validate on a simulator a learnable technique to decrease deviation of biopsied cores from the template schema during freehand, side-fire systematic prostate biopsy (sPBx) with the goal of reducing prostate biopsy (PBx) false-negatives, thereby facilitating earlier sampling, diagnosis and treatment of clinically significant prostate cancer.

PARTICIPANTS AND METHODS

Using a PBx simulator with real-time three-dimensional visualization, we devised a freehand, pitch-neutral (0°, horizontal plane), side-fire, transrectal ultrasonography (TRUS)-guided sPBx technique in the left lateral decubitus position. Thirty-four trainees on four Canadian and US urology programmes learned the technique on the same simulator, which recorded deviation from the intended template location in a double-sextant template as well as the TRUS probe pitch at the time of sampling. We defined deviation as the shortest distance in millimeters between a core centre and its intended template location, template deviation as the mean of all deviations in a template, and mastery as achieving a template deviation ≤5.0 mm.

RESULTS

All results are reported as mean ± sd. The mean absolute pitch and template deviation before learning the technique (baseline) were 8.2 ± 4.1° and 8.0 ± 2.7 mm, respectively, and after mastering the technique decreased to 4.5 ± 2.7° (P = 0.001) and 4.5 ± 0.6 mm (P < 0.001). Template deviation was related to mean absolute pitch (P < 0.001) and increased by 0.5 mm on average with each 1° increase in mean absolute pitch. Participants achieved mastery after practising 3.9 ± 2.9 double-sextant sets. There was no difference in time to perform a double-sextant set at baseline (277 ± 102 s) and mastery (283 ± 101 s; P = 0.39).

CONCLUSION

A pitch-neutral side-fire technique reduced template deviation during simulated freehand TRUS-guided sPBx, suggesting it may also reduce PBx false-negatives in patients in a future clinical trial. This pitch-neutral technique can be taught and learned; the University of Florida has been teaching it to all Urology residents for the last 2 years.

Detection of clinically significant prostate cancer with 18F-DCFPyL PET/multiparametric MR

PURPOSE

To assess whether ¹⁸F-DCFPyL PET/multiparametric (mp)MR contributes to the diagnosis of clinically significant (cs) prostate cancer (PCa) compared to mpMR in patients with suspicion of PCa, or patients being considered for focal ablative therapies (FT).

PATIENTS AND METHODS

This ethics review board-approved, prospective study included 55 men with suspicion of PCa and negative systematic biopsies or clinically discordant low-risk PCa (n = 21) or those being considered for FT (n = 34) who received ¹⁸F-DCFPyL PET/mpMR. Each modality, PET, mpMR, and PET/MR (using the PROMISE classification), was assessed independently. All suspicious lesions underwent PET/MR-ultrasound fusion biopsies.

RESULTS

There were 45/55 patients (81.8%) that had histologically proven PCa and 41/55 (74.5%) were diagnosed with csPCa. Overall, 61/114 lesions (53.5%) identified on any modality were malignant; 49/61 lesions (80.3%) were csPCa. On lesion-level analysis, for detection of csPCa, the sensitivity of PET was higher than that of mpMR and PET/MR (86% vs 67% and 69% [p = 0.027 and 0.041, respectively]), but at a lower specificity (32% vs 85% and 86%, respectively [p < 0.001]). The performance of MR and PET/MR was comparable. For identification of csPCa in PI-RADS ≥ 3 lesions, the AUC (95% CI) for PET, mpMR, and PET/MR was 0.75 (0.65-0.86), 0.69 (0.56-0.82), and 0.78 (0.67-0.89), respectively. The AUC for PET/MR was significantly larger than that of mpMR (p = 0.04).

CONCLUSION

PSMA PET detects more csPCa than mpMR, but at low specificity. The performance PET/MR is better than mpMR for detection of csPCa in PI-RADS ≥ 3 lesions.

CLINICAL REGISTRATION

NCT03149861.

MRI-guided Focused Ultrasound Ablation for Localized Intermediate-Risk Prostate Cancer: Early Results of a Phase II Trial

Background To reduce adverse effects of whole-gland therapy, participants with localized clinically significant prostate cancer can undergo MRI-guided focal therapy. Purpose To explore safety and early oncologic and functional outcomes of targeted focal high-intensity focused ultrasound performed under MRI-guided focused ultrasound for intermediate-risk clinically significant prostate cancer. Materials and Methods In this prospective phase II trial, between February 2016 and July 2019, men with unifocal clinically significant prostate cancer visible at MRI were treated with transrectal MRI-guided focused ultrasound. The primary end point was the 5-month biopsy (last recorded in December 2019) with continuation to the 24-month follow-up projected to December 2021. Real-time ablation monitoring was performed with MR thermography. Nonperfused volume was measured at treatment completion. Periprocedural complications were recorded. Follow-up included International Prostate Symptom Score (IPSS) and International Index of Erectile Function-15 (IIEF-15) score at 6 weeks and 5 months, and multiparametric MRI and targeted biopsy of the treated area at 5 months. The generalized estimating equation model was used for statistical analysis, and the Holm method was used to adjust P value. Results Treatment was successfully completed in all 44 men, 36 with grade group (GG) 2 and eight with GG 3 disease (median age, 67 years; interquartile range [IQR], 62-70 years). No major treatment-related adverse events occurred. Forty-one of 44 participants (93%; 95% CI: 82, 98) were free of clinically significant prostate cancer (≥6 mm GG 1 disease or any volume ≥GG 2 disease) at the treatment site at 5-month biopsy (median, seven cores). Median IIEF-15 and IPSS scores were similar at baseline and at 5 months (IIEF-15 score at baseline, 61 [IQR, 34-67] and at 5 months, 53 [IQR, 24-65.5], P = .18; IPSS score at baseline, 3.5 [IQR, 1.8-7] and at 5 months, 6 [IQR, 2-7.3], P = .43). Larger ablations (≥15 cm³) compared with smaller ones were associated with a decline in IIEF-15 scores at 6 weeks (adjusted P < .01) and at 5 months (adjusted P = .07). Conclusion Targeted focal therapy of intermediate-risk prostate cancer performed with MRI-guided focused ultrasound ablation was safe and had encouraging early oncologic and functional outcomes. © RSNA, 2021 Online supplemental material is available for this article See also the editorial by Tempany-Afdhal in this issue.

Can video games enhance surgical skills acquisition for medical students? A systematic review

OBJECTIVE

To systematically assess literature examining the impact of being a gamer or participating in video-game-based training on surgical skills acquisition amongst medical students.

BACKGROUND

Video games and surgical procedures share similar skills such as visuospatial abilities and hand-eye coordination; therefore, video games can be a valuable tool for surgical training amongst medical students. However, comprehensive, up-to-date systematic reviews are necessary to confirm.

METHODS

A systematic literature search of PubMed, MEDLINE, and EMBASE was performed in April 2020 with no limits set on the date of publication. Observational and randomized controlled studies were included. Quality and bias were assessed using the Newcastle-Ottawa Scale for nonrandomized studies and the Grading of Recommendations Assessment, Development and Evaluation system for randomized studies.

RESULTS

A total of 575 participants from 16 studies were included. The most common surgical skills tested were laparoscopy (n = 283, from 8 studies) and robotic surgery (n = 199, from 5 studies). A history of gaming and video-game-based training were associated with improved metrics in robotic surgery and laparoscopy, respectively. Neither was beneficial in arthroscopy or bronchoscopy. Studies using the Wii U and Underground reported significant improvement in overall laparoscopic performance.

CONCLUSION

Video games demonstrate potential as adjunctive training in surgical skill education, with a history of gaming and video-game-based training being beneficial in robotic surgery and laparoscopy, respectively. Methodological heterogeneity amongst included studies limit the ability to make conclusive decisions; thus, future studies with long-term follow-up, larger sample sizes, outcomes stratified by video-game characteristics, and up-to-date technology are necessary.

Case - Reflex anuria: A rare complication of retrograde pyelography

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Treatment of Advanced Renal Cell Carcinoma: Immunotherapies Have Demonstrated Overall Survival Benefits While Targeted Therapies Have Not

Context

Current guidelines suggest several targeted therapies (TTs) and immunotherapies (ITs) in the treatment of advanced or metastatic renal cell carcinoma (mRCC). Ideal sequencing of these treatments is unclear.

Objective

The primary objective was to evaluate the overall survival (OS) data of the treatments approved for mRCC. Secondary objectives included evaluating other signs of efficacy and adverse events.

Evidence acquisition

We reviewed the current Food and Drug Administration-approved treatments for mRCC. Trials associated with approval were reviewed. We also included pre- and postapproval publications when appropriate.

Evidence synthesis

There is minimal evidence supporting OS benefit for the nine approved TTs. They result in adverse events and are a considerable economic burden. For these reasons, their future role in mRCC treatment should be re-evaluated, given the emergence of IT that have demonstrated OS benefits. Accumulating long-term survival data with high-dose interleukin-2 treatment suggests that this older treatment could still be considered for eligible patients. Checkpoint inhibitors have shown promising OS and durable responses; as such, the high cost of treatment might be justified. However, the available evidence does not suggest that adding TT to IT would increase efficacy over IT alone, but would add toxicity.

Conclusions

Trial data supporting OS benefit are much stronger for ITs than for TTs. Combining checkpoint inhibitors with TTs has not been shown to produce better OS than checkpoint inhibitors alone, while more adverse events are present. Granting drug approvals based on efficacy without demonstrated OS benefit should be revisited.

Patient summary

Approved treatments for metastatic kidney cancer include targeted and immune-based therapies. The former commonly produces temporary tumour shrinkage, but survival benefits are unclear. All approved immunotherapies have increased survival, and a proportion of patients appear cured.

Diagnostic utility of axial imaging in the evaluation of hematuria: A systematic review and critical appraisal of the literature

INTRODUCTION

Increasing severity of hematuria is instinctively associated with higher likelihood of urological malignancy. However, the robustness of the evidentiary base for this assertion is unclear, particularly as it relates to the likelihood of upper urinary tract pathology. Thus, the value of axial imaging in the diagnostic workup of hematuria is unclear due to differences in the underlying patient populations, raising concern for sampling bias. We performed a systematic review to characterize the literature and association between severity of hematuria and likelihood of upper urinary tract cancer based on axial imaging.

METHODS

MEDLINE, EMBASE, and Cochrane were systematically searched for all studies reporting on adult patients presenting with hematuria. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for reporting of this systematic review and meta-analysis and the Newcastle-Ottawa Scale for risk of bias assessment. Degree of hematuria was classified as "microscopic," "gross," or "unspecified." Three urological malignancies (bladder, upper tract urothelial, and renal cancer) were considered both individually and in aggregate. Random-effects model with pairwise comparisons was employed to arrive at the axial imaging diagnostic yields.

RESULTS

Twenty-nine studies were included, of which six (20.7%) reported on patients with gross hematuria only, four (13.8%) reported on patients with microscopic hematuria only, seven (24.1%) included both, and 12 (41.4%) did not define or specify the severity of hematuria. Of 29 studies, two (6.9%) were at high-risk of bias, 21 (72.4%) at intermediate-risk, and six (20.7%) at low-risk of bias using the Newcastle-Ottawa criteria. Based on axial imaging, rates of diagnoses of renal, upper tract urothelial, and bladder cancers differed with differing severity of hematuria. Notably, rates of renal and upper tract urothelial carcinoma were higher in studies of patients with unspecified hematuria severity (3.6% and 10.4%, respectively) than among patients with gross hematuria (1.5% and 1.3%, respectively). When all urological malignancies were pooled, patients with unspecified hematuria were diagnosed more frequently (19.5%) compared to those with gross (15.3%) and microscopic hematuria (4.5%, difference=1.51%, 99% confidence interval 3.6-26.5%).

CONCLUSIONS

Lack of granularity in the available literature, particularly with regards to patients with unspecified hematuria severity, limits the generalizability of these results and highlights the need for future studies that provide sufficient baseline information, allowing for firmer conclusions to be drawn.

Natural History of Renal Angiomyolipoma Favors Surveillance as an Initial Approach

BACKGROUND

Traditionally, intervention was recommended for angiomyolipomas (AMLs) >4 cm due to the risk of catastrophic hemorrhage.

OBJECTIVE

To delineate the natural history of AMLs, including growth rates and need for intervention.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review was performed of an AML series from 2002 to 2013, which have been followed prospectively until 2018. We defined lesion size by maximum axial diameter and categorized lesion size at baseline.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A total of 458 patients with 593 AMLs, with a median follow-up of 65.2 mo, were identified. At diagnosis, 534 (90.1%) lesions were ≤4 cm. Forty-three interventions were required for 34 (5.7%) AMLs: 30 were treated with embolization, seven surgery, two with radiofrequency ablation (RFA), three with mammalian target of rapamycin (mTOR) inhibitors, and one with nivolumab when epithelioid AML was confirmed. The median size at intervention was 4.9 cm (range 1.1-29 cm).

RESULTS AND LIMITATIONS

Most (94%) of the lesions grew slowly (growth rate of <0.25 cm/yr) during the period of observation. The number of AMLs <4 cm needed to treat (NNT) prophylactically to prevent one emergent bleed would have been 136 or that to prevent one blood transfusion would have been 205. The NNT (<4 cm) prophylactically to prevent one elective intervention would have been 82. On multivariate analysis, there were significant differences in intervention rates based on tuberous sclerosis complex, size at presentation, and clinical presentation.

CONCLUSIONS

This large single-institution updated series of renal AMLs demonstrates that early intervention is not required, regardless of the traditional 4 cm cut-off. The vast majority of AMLs are indolent lesions that are predominantly asymptomatic and slow growing. Follow-up should be no more frequent than annually.

PATIENT SUMMARY

The majority of angiomyolipomas (AMLs) are indolent, slow-growing lesions that do not require intervention, regardless of size at presentation. We suggest that surveillance is a safe initial approach for patients presenting with AMLs.

Creating patient-centered radiology reports to empower patients undergoing prostate magnetic resonance imaging

INTRODUCTION

As we progress to an era when patient autonomy and shared decision-making are highly valued, there is a need to also have effective patient-centered communication tools. Radiology reports are designed for clinicians and can be very technical and difficult for patients to understand. It is important for patients to understand their magnetic resonance imaging (MRI) report in order to make an informed treatment decision with their physician. Therefore, we aimed to create a patient-centered prostate MRI report to give our patients a better understanding of their clinical condition.

METHODS

A prototype patient-centered radiology report (PACERR) was created by identifying items to include based on opinions sought from a group of patients undergoing prostate MRI and medical experts. Data was collected in semi-structured interviews using a salient belief question. A prototype PACERR was created in collaboration with human factors engineering and design, medical imaging, biomedical informatics, and cancer patient education groups.

RESULTS

Fifteen patients and eight experts from urology, radiation oncology, radiology, and nursing participated in this study. Patients were particularly interested to have a report with laymen terms, concise language, contextualization of values, definitions of medical terms, and next course of action. Everyone believed the report should include the risk of MRI findings actually being cancer in the subsequent biopsy.

CONCLUSIONS

A prostate MRI PACERR has been developed to communicate the most important findings relevant to decision-making in prostate cancer using patient-oriented design principles. The ability of this tool to improve patient knowledge and communication will be explored.

Predictors of prostate-specific antigen testing in men aged ≥55 years: A cross-sectional study based on patient-reported outcomes

OBJECTIVES

To examine the predictors of prostate-specific antigen discussion with a physician and prostate-specific antigen testing in men aged ≥55 years.

METHODS

Utilizing the USA Health Information National Trends Survey, 4th Ed., a cross-sectional study from 2011 to 2014 was carried out to analyze the factors predicting prostate-specific antigen testing and discussion in men ≥55 years. Associations between each covariate and prostate-specific antigen discussion/testing were determined. Multivariable logistic regression models were used to determine clinically relevant predictors of prostate-specific antigen discussion/testing. Due to multiple comparisons, the Bonferroni correction was used.

RESULTS

A total of 2731 men included in the Health Information National Trends Survey were analyzed. Several socioeconomic parameters were found to increase the likelihood of men aged ≥55 years to undergo prostate-specific antigen testing: living with a spouse, a higher level of education (college graduate or above), a higher income (>$50 000 annually) and previous history of any cancer. In contrast, current smokers were less likely to undergo prostate-specific antigen testing. Having a prostate-specific antigen discussion with a physician was more likely for men surveyed in 2014, for men who were living with a spouse, who had a higher annual income (>$50 000 annually) and those with a history of any cancer.

CONCLUSIONS

Significant inequalities in prostate-specific antigen testing and discussion exist among men in the USA, mainly driven by socioeconomic factors. Ideally, prostate-specific antigen testing and discussion should be based on relevant clinical factors with a shared decision-making approach for every man. Therefore, a better understanding of the socioeconomic factors influencing prostate-specific antigen testing/discussions can inform strategies to reduce existing gaps in care.

Primary analysis of a phase II study of metastasis-directed ablative therapy to PSMA (18F-DCFPyL) PET-MR/CT defined oligorecurrent prostate cancer

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Background: Despite maximal local therapies (MLT) (radical prostatectomy followed by radiotherapy [RT]), 20-30% of men will progress to incurable prostate cancer (PCa). Most recurrences in this scenario are characterized by rise in PSA with negative bone scan (BS) and computed tomography (CT). We conducted a phase II trial for men with rising PSA after MLT using 18F-DCFPyL (PSMA) PET-MR/CT followed by metastasis-directed therapy (MDT) to PET positive foci. We report the results of our primary analysis. Methods: Patients with rising PSA (0.4-3.0 ng/mL) after MLT, negative BS/CT and no prior salvage ADT were eligible. All patients underwent PSMA PET-MR and PET-CT. Those with limited disease burden amenable to MDT underwent either stereotactic ablative RT (SABR) or surgery (lymph node dissection). No ADT was used. The primary endpoint was biochemical response rate (complete [undetectable PSA] or partial [PSA decline ≥50% from baseline]) following MDT. A Simon’s two-stage study design was employed. Estimated time of delay in salvage ADT was calculated using the Kaplan-Meier method. Toxicity was prospectively recorded (CTCAE v4.0). Results: After a median of 63 months (range 3-180) post MLT, 72 patients underwent PSMA PET-MR/CT with median PSA 0.98 ng/mL (range 0.4-3.1). Sixteen patients had negative and 56 had positive PET-MR/CT scans, of which 37 (51%) were amenable to MDT. The median number of treated lesions was 2 (range 1-5). Of the treated patients, 30 (81%) had miT0N1M0 disease, 2 (5.5%) had miT0N1M1a, 2 (5.5%) had miT0N0M1a and 3 (8%) had miT0N0M1b. Twenty-seven patients underwent SABR (median 30 Gy in 3 fractions) and 10 had surgery. At a median of 11 months (range 1-29) post MDT, 8 patients (22%) had complete (CR) and 14 (38%) had partial (PR) responses. Among the 8 CRs, 5 had surgery and 3 had SABR; of the 14 PRs, 2 had surgery and 12 had SABR. The estimated median delay in salvage ADT for the entire cohort, PR and CR subgroups was 13 months (IQR 8-20), 16 months (IQR 13-20) and 30 months (IQR not reached), respectively. Two grade 2+ toxicities were observed, both in surgical patients: deep venous thrombosis and ureteric injury requiring stent placement. Conclusions: 18F-DCFPyL PET-MR/CT has high detection rates (78%) in men with rising PSA after MLT. We observed a favorable therapeutic index with MDT (60% response rate) for patients with metachronous PSMA-unveiled oligometastatic PCa following MLT. Phase III studies using validated intermediate clinical endpoints are needed before integration into routine practice. Clinical trial information: NCT03160794 .

How I Do It - MRI-ultrasound fusion prostate biopsy using the Fusion MR and Fusion Bx systems

There is increasing evidence to support the use of multiparametric magnetic resonance imaging (MRI) in men at risk for clinically significant prostate cancer to help identify lesions and inform biopsy. Randomized, level 1 evidence demonstrates that men who are managed with MRI and MRI-ultrasound fusion targeted biopsy (MRF-TB) have more clinically significant prostate cancer and less clinically insignificant prostate cancer detected and avoid biopsy altogether more often than men who undergo systematic, whole-gland prostate biopsy (SPB). Furthermore, strategies that incorporate MRF-TB have lower rates of upgrading on radical prostatectomy compared to SPB. However, generalizing this data to wider practice is challenging because there is a learning curve for interpreting MRI and performing MRF-TB, and some of the fusion technologies are better than others. We describe our group's early experience with the Fusion MR and Fusion Bx systems (Focal Healthcare, Toronto, ON, Canada). These products are designed with elastic fusion technology that is user-friendly, intuitive and accurate. The Fusion MR contouring system is straightforward and allows for contouring with several MRI sequences simultaneously. The Fusion Bx biopsy system has a semi-robotic arm that accounts for prostate deformation and patient movement and allows for freehand-like access, which is a seamless transition from SPB for clinicians. There were 68 lesions targeted in the first 51 patients. The overall cancer detection rate was 22%/61%/83% for PI-RADS 3/4/5, respectively. The Gleason grade group 2 prostate cancer or higher rate was 6%/47%/75% for PI-RADS 3/4/5, respectively. There were no major complications in this cohort of patients. Limitations of this study include small number of patients and lack of formal follow up to rule out sepsis. Overall, the Fusion MR and Fusion Bx systems are accurate, straightforward and safe to use for MRF-TB. Early experience does not show any significant learning curve.

18F-DCFPyL PET/CT in Patients with Subclinical Recurrence of Prostate Cancer: Effect of Lesion Size, Smoothing Filter, and Partial-Volume Correction on PROMISE Criteria

Our purpose was to determine the effect of a smoothing filter and partial-volume correction (PVC) on measured prostate-specific membrane antigen (PSMA) activity in small metastatic lesions and to determine the impact of these changes on molecular imaging PSMA (miPSMA) scoring. Methods: Men who had biochemical recurrence of prostate cancer with negative findings on CT and bone scintigraphy were referred for ¹⁸F-DCFPyL (2-(3-(1-carboxy-5-[(6-¹⁸F-fluoro-pyridine-3-carbonyl)-amino]-pentyl) PET/CT. Examinations were performed on 1 of 2 different brands of PET/CT scanner. All suspected tumor sites were manually contoured on coregistered CT and PET images, and each was assigned an miPSMA score as per the PROMISE criteria. The PVC factors were calculated for every lesion using the anatomic CT and then applied to the unsmoothed PET images. The miPSMA scores, with and without the corrections, were compared, and a simplified rule-of-thumb (RoT) correction factor (CF) was derived for lesions at various sizes (<4 mm, 4-7 mm, 7-9 mm, and 9-12 mm). This CF was then applied to the original dataset and the miPSMA scores that were obtained using the RoT CF were compared with those obtained using the actual corrections. Results: There were 75 men (median age, 69 y; median serum PSA, 3.69 μg/L) with 232 metastatic nodes less than 12 mm in diameter (mean lesion volume, 313.5 ± 309.6 mm³). The mean SUV_max before and after correction was 11.0 ± 9.3 and 28.5 ± 22.8, respectively (P < 0.00001). The mean CF for lesions smaller than 4 mm (n = 22), 4-7 mm (n = 140), 7-9 mm (n = 50), and 9-12 mm (n = 20) was 4 (range, 2.5-6.4), 2.8 (range, 1.6-4.9), 2.3 (range, 1.6-3.3), and 1.8 (range, 1.4-2.4), respectively. Overall, the miPSMA scores were concordant between the corrected dataset and the RoT dataset for 205 of 232 lesions (88.4%). Conclusion: A smoothing filter and PVC had a significant effect on measured PSMA activity in small nodal metastases, impacting the miPSMA score.

Improving quality of health-related quality of life (HRQOL) reporting in phase III randomized controlled trials (RCTs) of metastatic prostate cancer (mPC)

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Background: HRQOL data are increasingly used to guide patient care and health policy. However, their utility can be compromised by inadequate quality of HRQOL reporting (QHR). We aimed to evaluate QHR in phase III RCTs of mPC. Methods: A systematic review following PRISMA guidelines identified published manuscripts of phase III RCTs of mPC assessing systemic therapies (excluding androgen deprivation therapy and bone targeting agents) between 1990 - 2019. Supplements, references and companion publications were reviewed. QHR was independently quantified using the Minimum Standard Checklist for Evaluating HRQOL Outcomes in Cancer Clinical Trials (MSC, range 0-11) by 2 investigators. QHR is “probably robust” if MSC score is ≥8 and all 3 mandatory items (baseline compliance, missing data, and psychometric properties) are reported; “limited” if score is 5-7; and “very limited” if score is ≤4. Results: HRQOL was the primary (11%), secondary (61%), explorative (21%), and unspecified (7%) endpoint in 57/76 (75%) RCTs, and reported in 46/57 (81%). Primary HRQOL endpoints were pain palliation only. MSC scores ranged 2 – 11. QHR was mostly limited (Table). Most RCTs did not report mode of administration (82%), rationale for selected instrument (65%), or missing data (59%). Other common limitations were: unreported baseline compliance (35%), lack of culturally validated measure (33%), clinical significance not discussed (33%), no hypotheses stated (28%), and inadequate coverage of HRQOL domains (26%). QHR has improved since 2015, with the median MSC score reaching 8 (Table). Conclusions: QHR has improved considerably over time, with many recent phase III RCTs in mPC reporting “probably robust” HRQOL data. Within existing resource constraints however, nonreporting and methodologic deficiencies still remain. The use of standard checklists may further enhance QHR and promote high quality HRQOL research.[Table: see text]

Salvage radical prostatectomy following focal therapy: functional and oncological outcomes

OBJECTIVES

To report the oncological and functional outcomes of salvage radical prostatectomy (sRP) after focal therapy (FT).

PATIENTS AND METHODS

A retrospective review of all patients who underwent sRP after FT was performed. Clinical and pathological outcomes focussed on surgical complications, oncological, and functional outcomes.

RESULTS

In all, 34 patients were identified. The median (interquartile range [IQR]) age was 61 (8.25) years. FT modalities included high-intensity focussed ultrasound (19 patients), laser ablation (13), focal brachytherapy (one) and cryotherapy (one). The median (IQR) time from FT to recurrence was 10.9 (17.6) months. There were no rectal or ureteric injuries. Two (5.9%) patients had iatrogenic cystotomies and four (11.8%) developed bladder neck contractures. The mean (sd) hospital stay was 2.5 (2.1) days. The T-stage was pT2 in 14 (41.2%) patients, pT3a in 16 (47.1%), and pT3b in four (11.8%). In all, 13 (38%) patients had positive surgical margins (PSMs). Six (17.6%) patients received adjuvant radiotherapy (RT). At a mean follow-up of 4.3 years, seven (20.6%) patients developed biochemical recurrence (BCR), and of these, six (17.6%) patients required salvage RT. PSMs were associated with worse BCR-free survival (hazard ratio 6.624, 95% confidence interval 2.243-19.563; P < 0.001). The median (IQR) preoperative International Prostate Symptom Score and International Index of Erectile Function score was 7 (4.5-9.5) and 23.5 (15.75-25) respectively, while in the final follow-up the median (IQR) values were 7 (3.5-11) and 6 (5-12.25), respectively (P = 0.088 and P < 0.001). At last follow-up, 31 (91.2%) patients were continent, two (5.9%) had moderate (>1 pad/day) incontinence, and one (2.9%) required an artificial urinary sphincter.

CONCLUSIONS

sRP should be considered as an option for patients who have persistent clinically significant prostate cancer or recurrence after FT. PSMs should be recognised as a risk for recurrent disease after sRP.