Concordance of MRI-Guided Fusion and Systematic 12-Core Prostate Biopsy for the Detection of Prostate Cancer

Background

MRI-guided fusion biopsy is increasingly utilized over systematic 12-core biopsy for men with MRI-visible prostate lesions.

Patients and Methods

Patients with MRI visible lesions who underwent MRI-guided fusion and systematic 12-core biopsy from 2016-2020 in the Intermountain Healthcare (IHC) system were consecutively analyzed. This was in the setting of a continuous quality assurance initiative among the reading radiologists. Primary outcome was prostate cancer (PCa) detection defined by Gleason grade group (GGG) 1 or higher. Clinically significant cancer (CSC) was defined as GGG 2 or higher. Patients were stratified by biopsy date, 2016-2017 and 2018-2021, and lesions were stratified by PI-RADS v2 category.

Results

A total of 184 patients with 324 MRI-detectable lesions underwent both biopsy modalities in the IHC system from 2016 to 2021. CSC was detected in 23.5% of MRI-guided fusion biopsies. Comparing PI-RAD v2 categories 1-3 to categories 4-5, rate of CSC was 10% and 42% respectively. MRI-guided fusion and systematic 12-core biopsies were concordant for PCa in 77% of men and CSC in 83%. MRI-guided fusion biopsy detected PCa in 26/103 and CSC in 20/131 men in whom systematic 12-core biopsy was negative. Systematic 12-core biopsy detected PCa in 17/94 and CSC in 11/122 men in whom MRI-guided fusion was negative.

Conclusions

Omitting MRI-guided fusion or systematic 12-core biopsy would have resulted in underdiagnosis of CSC in 11% or 6% of patients respectively. Combining biopsies increased detection rate of CSC. This was in the setting of a continuous quality assurance program at a large community-based hospital.

Incidence and cost of radical prostatectomy for NCCN low-risk prostate cancer in Utah

232

Background: Guidelines Support active surveillance (AS) as the preferred treatment for men with NCCN low-risk prostate cancer (Gleason 3+3, prostate-specific antigen [PSA] <10 ng/ml, ≤T2a). Recent work from Mahal BA et al. (JAMA 2019) reports AS rates are increasing, but only 42.1% of men with low-risk prostate cancer underwent AS in 2015. Low-risk prostate cancer accounted for 30.1% of diagnoses. The majority of Utah residents treated for prostate cancer receive therapy at either The Huntsman Cancer Institute or Intermountain Healthcare facilities. We modeled the costs associated with the presumptive overtreatment of men with low-risk disease treated in 2017-2019. Methods: Data from The Huntsman Cancer Institute and Intermountain Healthcare cancer databases from 2017 to 2019 were retrospectively analyzed. Men with available pathologic, laboratory and clinical data who had undergone prostatectomy were stratified by having NCCN low, intermediate, and high-risk disease. Rates of radical prostatectomy by year and institution were analyzed. The cost of prostatectomy compared to AS was estimated to be $14,453 from recent work by Trogdon JG et al. (JAMA Oncol 2019). Results: Data was available for 1,155 Utahn men (Table). Of the 1155 surgeries performed, 69 (6%) were in low-risk patients. The total costs of care that might have been avoided over these three years are estimated to be $1 million. Conclusions: Approximately 6% of prostatectomies performed in Utah are in men with NCCN low-risk prostate cancer. While these rates are lower than the national average, we estimate approximately $1 million in medical costs and toxicities could be deferred had these patients opted for AS. Work is ongoing to characterize clinical toxicity of treatment in these men, and a multi-institutional collaborative education outreach program to reduce overtreatment is in development. [Table: see text]

Concordance of MRI-guided and systematic prostate biopsy for the detection of prostate cancer (PCa)

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Background: MRI/US guided biopsy (fusion biopsy) is increasingly utilized over systemic 12-core transrectal ultrasound biopsy (12-core biopsy) for men with MRI-visible prostate lesions. Methods: Patients with MRI visible prostate lesions who underwent fusion and 12-core biopsy from 2016-2020 in the Intermountain Healthcare (IHC) system were consecutively analyzed. This was in the setting of a continuous quality assurance initiative among the reading radiologists. Primary outcome was PCa detection defined by Gleason grade group (GGG) 1 or higher. Clinically significant cancer (CSC) was defined as GGG 2 or higher. Patients were stratified by date biopsy was performed, 2016-2017 and 2018-2020, and lesions were stratified by PI-RADS v2 category. For men with multiple lesions, the highest PI-RADS v2 category lesion was used. Results: A total of 142 men with 254 MRI-detectable lesions underwent both fusion and 12-core biopsies in the IHC system from 2016 to 2020. CSC was detected in 21.6% (55/254) of fusion biopsies. Comparing PI-RAD v2 categories 1-3 to PI-RADS v2 categories 4-5, the PPV for detecting CSC was 9% (15/162) compared to 44% (40/92) respectively. Fusion and 12-core biopsies were concordant for any PCa in 79% of men (112/142) and CSC in 83% (118/142). Fusion biopsy detected any PCa in 22/84 (26%) and CSC in 15/103 (15%) of men in whom 12-core biopsy was negative. 12-core biopsy detected any PCa in 8/70 (11%) and CSC in 9/97 (9%) of men in whom fusion was negative. In total, 15 patients (11%) had a CSC that would have been missed if fusion biopsy was omitted while 9 (6%) had a CSC that would have been missed without 12-core biopsy. Conclusions: Omitting fusion or 12-core biopsy for PI-RADS v2 lesions would have resulted in a missed CSC in 11% or 6% of patients from 2016-20, respectively. The combination of MRI/US-guided fusion biopsy and systematic 12-core biopsy increased detection rate of CSC. These results are in the setting of a continuous, multi-disciplinary quality assurance program and results are not necessarily applicable to other healthcare systems. [Table: see text]

Accuracy of prostate imaging reporting and data system (PI-RADS v2) in the detection of prostate cancer (PCa)

e17604

Background: MRI-targeted biopsy is increasingly utilized over standard 12-core transrectal ultrasound (TRUS) biopsy for men with MRI-visible prostate lesions. Some clinicians defer biopsy for PI-RADS v2 category 1 and 2 lesions per the PRECISION Study (Kasivisvanathan et. Al, NEJM, 2018). The aim of this study was to independently validate the accuracy of PI-RADS v2 in detecting prostate cancer (PCa) when applied to MRI/US fusion-guided biopsies in an independent cohort of 156 patients from a large integrated community health system. Methods: Men undergoing MRI/US fusion-guided biopsy from 2016-2020 in the Intermountain Healthcare system were consecutively analyzed in this retrospective study. MRI were interpreted from four abdominal fellowship trained radiologists all with at least 5 years of experience. Fusion biopsies were performed by two urologists. Men were stratified into groups based on their PI-RADS v2 category 1-5. Biopsies were considered positive when Gleason ≥3+3. Results: A total of 156 men had 258 lesions for which they underwent MRI/US fusion-guided biopsies in the Intermountain Healthcare system from 2016 to 2020. The PCa detection rate for PIRADSv2 category 1-2 was 29.8%, category 3 32.6%, and category 4-5 37.6%. PIRADS v2 category 1, 2, 3, 4, and 5 yielded any PCa in 25, 15.9, 23.8, 53.1, and 66.7%, respectively (Table). PIRADS v2 category 1-2, 3, and 4-5 yielded any PCa in 16.8%, 23.8%, and 57.7%, respectively. Conclusions: PI-RADS v2 categories generally correlate with PCa detection rates, however, to avoid biopsy, the test must be both sensitive and specific, with low false negative rates. In our institution, we show that PI-RADS 1, 2, and 3 do not rule out the presence of PCa, and therefore should not be used as the sole factor in determining the need for prostate lesion biopsy. [Table: see text]

CardioWest total artificial heart: a retrospective controlled study

The CardioWest total artificial heart (TAH) is a pneumatic device that is used as a bridge to heart transplantation and the only TAH available that totally replaces the failing ventricles. It has been utilized in selected centers in the U.S.A. with approval from the Food and Drug Administration. Strict criteria have been developed to select candidates to be bridged with the TAH. The patient must be a heart transplant candidate of age >18 and <59 years with a body surface area (BSA) > or = 1.7 m2, cardiac index (CI) <2.0 L/min/m2, and 2 inotropic agents or 1 plus an intraaortic balloon pump (IABP). A total of 24 heat transplant candidates (Group A) met the entry criteria and underwent placement of the TAH between January 1993 and July 1996. Group A consisted of 23 males; 16 patients had an IABP. The control group (Group B) consisted of 18 heart transplant candidates who met the TAH entry criteria but never received a TAH. Group B consisted of 15 males; 14 patients had an IABP. Preimplantation pulmonary vascular resistance (PVR) (Wood units), serum creatinine (mg/dl), and total bilirubin (mg/dl) were determined in both groups. The mean values for Groups A and B were, respectively, age: 47 and 47 years, BSA: 2.01 and 1.93 m2, CI: 1.5 and 1.8 L/min/m2, PVR: 2.88 and 2.47 Wood units, creatinine: 1.5 and 1.6 mg/dl, and bilirubin: 1.8 and 1.4 mg/dl. In Group A, 1 patient died on the TAH, 1 patient died after transplant, and 22 patients reached transplant and were discharged home for a survival rate of 91.7%. In Group B, 10 patients died while waiting for a heart transplant. Of the 8 patients transplanted, 7 survived and were discharged home for a survival rate of 38.9% (p = 0.0003). In summary the CardioWest TAH provided an excellent and successful method of bridging patients to heart transplantation with a reasonable risk.

The CardioWest total artificial heart bridge to transplantation: 1993 to 1996 national trial

BACKGROUND

We performed a controlled study of a total artificial heart in bridge to transplantation. We hypothesized that the CardioWest total artificial heart used in a selected population of decompensating cardiac transplantation candidates would result in improved survival compared with matched controls.

METHODS

The CardioWest trial started in 1993 in six United States institutions under an investigational device exemption from the Food and Drug Administration. Four centers contributed 27 implant and 18 matched retrospective control patients.

RESULTS

Of the implant patients, 25 (93%) received a transplant, 24 (89% of the total, 96% of those transplanted) were discharged and are currently surviving. In the control group, 10 patients died awaiting transplantation, 8 received a transplant, and 7 were discharged with 6 surviving (p = 0.00001). All adverse events were documented with respect to time. Thirteen serious adverse events occurred, 11 of which occurred in the 2 patients that died during implant.

CONCLUSIONS

In a selected group of patients with endstage heart disease, use of the CardioWest total artificial heart is lifesaving. When compared with the series of matched retrospective controls, a significant improvement in survival was found in the CardioWest implant group.

Infections with the CardioWest total artificial heart

The CardioWest total artificial heart is a pneumatically driven device that totally replaces the failing ventricles. It is currently used as a bridge to heart transplantation in selected centers in the United States under a study by the Food and Drug Administration. Twenty-seven patients have undergone placement of the total artificial heart since 1993 with the intention to bridge to transplantation. Inclusion criteria included candidacy for heart transplantation, cardiac index (CI) < 2.0 L/min/m2, and maximal inotropic support. The population consisted of 25 men and 2 women of mean +/- SD age 46.5 +/- 10.3 years, body surface area 2.01 +/- 0.17 m2, and duration of implant 52 +/- 42 days. Initial diagnosis included ischemic cardiomyopathy (n = 10), idiopathic (n = 10), viral (n = 4), valvular (n = 2), and graft failure (n = 1). Infectious complications were defined as systemic (evidence of leukocytosis or fever) or local. The population experienced 64 infections (range, 0-9 per patient): 45 systemic and 19 local. Three patients did not experience any infection. Twenty-five patients reached transplantation, and were discharged home for a survival rate of 92.6%. Two patients died during the bridge, one because of mechanical failure, and one because of infection (mediastinitis). Therefore, death attributable to infections occurred in 3.7%. Previous reports of the total artificial heart experience in the late 1980s described death rates as high as 40%. Although infectious complications are common in patients who are bridged to heart transplantation with the total artificial heart, mortality from infections is 10 times less than previously reported. This may be the result of a better strategy for bridging to transplantation that includes patient selection, mobilization, early central line removal, and waiting until all possible infections are resolved before proceeding to transplantation.

International experience with the CardioWest total artificial heart as a bridge to heart transplantation

As the number of potential heart donors remains constant and the number of potential recipients continuous to increase, the need for circulatory devices to bridge patients becomes more important. The CardioWest total artificial heart (TAH) is a pneumatic, implantable system that totally replaces the failing ventricles. It has been utilized worldwide as a bridge to heart transplantation in 79 patients. There were 73 males and six females who received the TAH. Currently three patients remain on the device waiting for transplantation. A total of 55 patients (70%) were transplanted of which 50 survived (91% of patients transplanted) and were discharged home. Idiopathic/dilated cardiomyopathy was the most common etiology followed by ischemic cardiomyopathy. The mean duration of implant was 34 days (range 0-186 days) and the mean age of the group was 45 years (range 16-62 years). Twenty-one patients died while on the device. Multiple organ failure was the major cause of death. There were a total of 255 complications in this group that included reoperation, bleeding, hepatic failure, renal failure, respiratory failure, neurologic events, thromboembolic events, infections, device malfunction, and fit complications. This represented a mean complication rate of three events per patient. The survival rate for the CardioWest TAH of 91% of the patients who reached transplantation is an improvement over that of the Symbion registry (55% of those transplanted) probably as a result of a better patient selection and better control of the coagulation system. These results are also comparable to those survival results obtained with other biventricular and left ventricular assist devices currently available.

Nuclear magnetic resonance analysis of cell metabolism

Nuclear magnetic resonance (NMR) continues to be a useful tool for the study of cellular metabolism. A variety of NMR techniques have been developed or newly applied to the analysis of cell systems. Many of these techniques are particularly useful for the analysis of immobilized cell bioreactors. The use of several NMR techniques has been an integral part of recent comprehensive metabolic studies. Novel computer-based models and methods have been developed which may make NMR study of metabolism more accessible and powerful.

Successful use of the total artificial heart as a bridge to transplantation with no mediastinitis

High rates of infection, especially mediastinitis, have been reported with the use of the total artificial heart (TAH), thereby limiting its usefulness. We have used the TAH as a bridge to transplantation with only minor infectious complications and a zero incidence of mediastinitis. Between February 1988 and August 1990, the TAH was inserted at Loyola University Medical Center in 19 patients, ages 16 to 64 years (mean, 44 years). Seventeen patients (89%) underwent transplantation within 1 to 34 days (mean, 9.8 days). Of the patients who did not undergo transplantation, one was brain dead and the other died of bleeding diathesis. Early (30-day) deaths occurred in two patients (11.7%): acute rejection at 18 days and multiple cerebral infarcts at 14 days. Three late deaths (17.6%) occurred: one patient, cytomegalovirus and pneumocystis pneumonia at 4 months; one patient, bronchopneumonia and multisystem failure at 9 months; and one patient, chronic rejection at 14 months. Minor infectious complications during the TAH implantation included Enterobacter pneumonia treated with antibiotics and positive sputum cultures (Escherichia coli; Candida), with no clinical evidence of infection in two patients. No cases of mediastinitis occurred either while the TAH was implanted or after transplantation. All patients were on antibiotics while the device was in place.

CONCLUSION

Our experience with the TAH shows this to be an excellent device for successful bridging of patients for heart transplantation. We have had minimal infectious complications and none directly attributed to the use of this device. This device should continue to be used safely as a bridge to transplantation.

Antidepressant binding sites in brain: autoradiographic comparison of [3H]paroxetine and [3H]imipramine localization and relationship to serotonin transporter

Binding of two different antidepressant drugs, [3H]paroxetine and [3H]imipramine in 30 rat brain regions was visualized, compared and quantified by means of autoradiography and densitometry. Specific binding of [3H]paroxetine to coronal sections of diencephalon represented 85% of total binding and was saturable and of high affinity (KD, 0.36 +/- 0.07 nM) with a maximum number of binding sites of 276 +/- 41 fmol/mg protein. The autoradiograms showed a heterogenous distribution of [3H]paroxetine in brain with selective accumulation of label in brain regions known to contain serotonergic terminals, axons and cell bodies (amygdaloid and raphe nuclei, superior colliculus, substantia nigra and medial forebrain bundle). Binding was displaced selectively with other serotonin uptake inhibitors (clomipramine and fluoxetine) and almost abolished by lesioning the serotonergic neurons with p-chloroamphetamine. The desipramine-sensitive [3H]imipramine binding was more diffuse with relatively high density in cerebral cortex and hippocampus and was only decreased partially in animals treated with p-chloroamphetamine. The results indicate that [3H]paroxetine, but not [3H]imipramine, is a ligand of choice to selectively label serotonergic structures in brain.

Diagnosis of coronary sinus diverticulum in Wolff-Parkinson-White syndrome using coronary angiography

The entity of Wolff-Parkinson-White Syndrome and coronary sinus diverticula when the bypass tract is posteroseptal in location has been described recently. The presence of this diverticulum may complicate arrhythmia surgery and could potentially add to the risk of catheter ablation. We describe a case of Wolff-Parkinson-White Syndrome in which the diagnosis of a coronary sinus diverticulum was made preoperatively using late-phase coronary angiography and suggest angiography be considered in patients with posteroseptal bypass tracts prior to surgery or catheter ablation.

Cardiac transplantation

Cardiac transplantation is now an accepted therapeutic procedure in the management of patients suffering from end-stage congestive heart failure. The advances in myocardial preservation, long-distance procurement, immunosuppression, improvement in the treatment of infectious diseases, and utilization of endomyocardial biopsy in the diagnosis of rejection have made its application widespread and resulted in improved survival.

Multivariate discriminant analysis of risk factors for operative mortality following isolated coronary artery bypass graft. Loyola University Medical Center experience, 1970 to 1984

The Loyola Open-Heart Registry is a fully operational database that contains detailed data on approximately 9,000 patients who have undergone coronary bypass or cardiac valve replacement from January 1970 to December 1984. We analyzed the registry data using multivariate discriminant analysis to identify and quantitate those factors that might predict operative mortality (OM) for patients undergoing coronary artery bypass grafts at Loyola University Medical Center: Operative mortality was defined as death within 30 days following surgery. A total of 50 clinical and angiographic variables were analyzed for possible univariate association with operative mortality. Twenty-two variables were found to have significant univariate association with OM, and these 22 variables were subjected to multivariate discriminant analysis. For patients undergoing isolated, elective coronary artery bypass, the factors found to be predictive of OM are age (greater than 70) (F = 11.57), severe (more than six stenoses) coronary artery disease (F = 5.81), diffuse disease (F = 5.54), positive family history (F = 5.17), and number of coronary arteries bypassed (F = 4.78).