Primary Staging Research Articles

Evaluating the impact of 18F-FDG-PET-CT on risk stratification and treatment adaptation for patients with muscle-invasive bladder cancer (EFFORT-MIBC): a phase II prospective trial

BackgroundThe outcome of patients with muscle-invasive bladder cancer (MIBC) remains poor, despite aggressive treatments. Inadequate primary staging, classically performed by computed tomography (CT)-imaging, could lead to inappropriate treatment and might contribute to these poor results. Although not (yet) adapted by international guidelines, several reports have indicated the superiority of 18F-fluorodeoxyglucose-positron emission tomography-CT (18F-FDG-PET-CT) compared to CT in the detection of lymph node and distant metastases. Thereby the presence of extra-vesical disease on 18F-FDG-PET-CT has been correlated with a worse overall survival. This supports the hypothesis that 18F-FDG-PET-CT is useful in stratifying MIBC patients and that adapting the treatment plan accordingly might result in improved outcome.MethodsEFFORT-MIBC is a multicentric prospective phase II trial aiming to include 156 patients. Eligible patients are patients with histopathology-proven MIBC or ≥ T3 on conventional imaging treated with MIBC radical treatment, without extra-pelvic metastases on conventional imaging (thoracic CT and abdominopelvic CT/ magnetic resonance imaging (MRI)). All patients will undergo radical local therapy and if eligible neo-adjuvant chemotherapy. An 18F-FDG-PET-CT will be performed in addition to and at the timing of the conventional imaging. In case of presence of extra-pelvic metastasis on 18F-FDG-PET-CT, appropriate intensification of treatment with metastasis-directed therapy (MDT) (in case of ≤3 metastases) or systemic immunotherapy (> 3 metastases) will be provided. The primary outcome is the 2-year overall survival rate. Secondary endpoints are progression-free survival, distant metastasis-free survival, disease-specific survival and quality of life. Furthermore, the added diagnostic value of 18F-FDG-PET-CT compared to conventional imaging will be evaluated and biomarkers in tumor specimen, urine and blood will be correlated with primary and secondary endpoints.DiscussionThis is a prospective phase II trial evaluating the impact of 18F-FDG-PET-CT in stratifying patients with primary MIBC and tailoring the treatment accordingly. We hypothesize that the information on the pelvic nodes can be used to guide local treatment and that the presence of extra-pelvic metastases enables MDT or necessitates the early initiation of immunotherapy leading to an improved outcome.Trial registrationThe Ethics Committee of the Ghent University Hospital (BC-07456) approved this study on 11/5/2020. The trial was registered on ClinicalTrials.gov (NCT04724928) on 21/1/2021.

Single-Center Comparison of [64Cu]-DOTAGA-PSMA and [18F]-PSMA PET-CT for Imaging Prostate Cancer.

Introduction: the diagnostic performance of [64Cu]-DOTAGA-PSMA PET–CT imaging was compared retrospectively to [18F]-PSMA PET–CT in prostate cancer patients with recurrent disease and in the primary staging of selected patients with advanced local and possible metastatic disease. Methods: We retrospectively selected a total of 100 patients, who were consecutively examined in our department, with biochemical recurrence after radical prostatectomy or who had progressive local and possible metastatic disease in the last 3 months prior to this investigation. All patients were examined with a dedicated PET–CT scanner (Biograph; Siemens Healthineers). A total of 250 MBq (3.5 MBq per kg bodyweight, range 230–290 MBq) of [64Cu]-DOTAGA-PSMA or [18-F]-PSMA was applied intravenously. PET images were performed 1 h post-injection (skull base to mid-thigh). The maximum standardized uptake values (SUVmax) of PSMA-positive lesions and the mean standardized uptake value (SUVmean) of the right liver lobe were measured. Results: All but 9/50 of the patients (18%; PSA range: 0.01–0.7 µg/L) studied with [64Cu]-DOTAGA-PSMA and 6/50 of the ones (12%; PSA range: 0.01–4.2) studied with [18F]-PSMA had at least one positive PSMA lesion shown by PET–CT. The total number of lesions was higher with [64Cu]-DOTAGA-PSMA (209 vs. 191); however, the median number of lesions was one for [64Cu]-DOTAGA-PSMA and two for [18F]-PSMA. Interestingly, the median SUVmean of the right liver lobe was slightly higher for [18F]-PSMA (11.8 vs. 8.9). Conclusions: [64Cu]-DOTAGA-PSMA and [18F]-PSMA have comparable detection rates for the assessment of residual disease in patients with recurrent or primary progressive prostate cancer. The uptake in the liver is moderately different, and therefore at least the SUVs of the lesions in both studies would not be comparable.

1560 Unusual Sites of Colorectal Cancer Metastases – A Complete Systematic Review

Abstract Background While colorectal cancer (CRC) usually metastasizes to liver, lungs, and central nervous system, spread to more unusual sites is rarely reported in literature. We aimed to investigate unusual colorectal metastases (UCRM), their clinical course and disease progression. Method MEDLINE, EMBASE and Cochrane Library were searched by independent reviewers to identify clinical studies to date that reported UCRM and relevant demographic/clinical data were extracted. Results We identified 349 patients, involving 28 sites (bone, musculo-skeletal, skin, brain/spinal cord, head, eye, oral mucosa, thyroid, mediastinum, heart, bronchus, breast, biliary/GI tract, stomach, pancreas, spleen, adrenal, urinary tract, inguinal canal, ovaries, vagina, vulva, testes, spermatic cord, prostate, penis) with male preponderance and median age of 59 years (IQR=54.5-65). These were diagnosed at a median interval of 18 months (IQR=6-36)) after a median follow-up of 12 months (IQR=6-22.5). More were metachronous (n = 210) with recurrence rate of 15.75%. Primary CRC staging revealed T3 in 61% (28%-T4), equal distribution of N0/N1 (38%/37%) and M0 in 85%. 74% of primaries were surgically resected (96%=adenocarcinomas) and 54% underwent adjuvant therapy. UCRM were resected in 45% of cases and showed same histology as primary. 30% had chemotherapy. Only 8% were palliated. Overall morality was 35.24%. Conclusions This is the first comprehensive review looking at clinical course and outcomes of patients with UCRM. Most of these developed in patients with primary T3/N0 staging. Outlook of these patients is comparable to those with usual metastatic disease. Judicious and rigorous surveillance is the key to early detection and timely management.

Prognostic Prediction of BRCA Mutations by 18F-FDG PET/CT SUVmax in Breast Cancer

Objectives:This study aimed to investigate the prognostic prediction of germline BRCA1 and BRCA2 mutations by comparing the maximum standardized uptake value (SUVmax) obtained from 18fluoride-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT), which is considered a prognostic factor in breast cancer (BC).Methods:Retrospective interdisciplinary laboratory results of 92 patients with BC who had germline BRCA1 or BRCA2 mutation profiles and underwent 18F-FDG PET/CT were compared. Genotyping was made by next-generation sequencing, and PET/CT scans were re-evaluated. The histopathological data, genetic results, and clinical demographics of all patients were recorded. Patients were divided into two groups in accordance with the presence of germline BRCA1 and/or BRCA2 mutations. Between-group statistical comparison was performed.Results:In PET/CT performed for primary staging, patients with BRCA-positive BC had significantly higher SUVmax (p=0.039), larger tumor size (p=0.025), and presence of axillary nodal metastases (p=0.023) than patients with BRCA-negative BC. Although the Ki-67 index was higher in the BRCA-positive group than BRCA-negative group, this difference was not significant (p=0.157). Moreover, in the BRCA-positive and negative groups, SUVmax, Ki-67 index, and tumor size, grade, and stage were significantly correlated with each other.Conclusion:The results of this study showed a strong association between BRCA mutations and SUVmax, which indicates the poor prognosis of BC.

SC280 - PSMA PET/CT imaging for primary staging of intermediate and high-risk prostate cancer

SC280 - PSMA PET/CT imaging for primary staging of intermediate and high-risk prostate cancer

Diagnostic performance of PET/CT in primary malignant bone tumors

BackgroundNowadays, PET/CT plays a substantial role in the diagnosis of different types of tumor by its ability to provide combined functional and anatomic imaging in the same session. The purpose of this study is to evaluate the added value of PET/CT in staging and re-staging of primary malignant bone tumors.ResultsOut of the studied 40 patients, 7 patients were referred for primary staging of different types of histologically proven primary malignant bone tumors, their FDG-PET/CT studies yielded additional diagnostic information in 28.6% of them. Thirty three patients were referred either for assessment of treatment response or for follow-up to detect any viable lesions; FDG-PET/CT was more sensitive and specific than CT in follow-up and assessment of treatment response with PET/CT sensitivity 94.4%, specificity 86.7%, and total accuracy 90.9% and CT sensitivity 88.2%, specificity 81.2%, and total accuracy 84.8%.ConclusionsPET/CT was an accurate imaging modality in evaluation of primary malignant bone tumors regarding tumor staging, assessment of therapeutic response and detection of metastatic disease as compared to CT.

Обследование пациентов с раком предстательной железы высокого риска: реальная практика в России

Introduction. Approaches to the diagnosis and staging of localized and locally advanced high-risk prostate cancer (PCa-НR) continue to be actively researched and improved. Materials and methods. In order to understand some of the controversial and controversial issues regarding the diagnosis of PCа-НR, a survey was conducted, in which 250 specialists took part – oncourologists, urologists, andrologists, specializing in the treatment / observation of patients with prostate cancer (PCа). The survey was conducted within the urological information portal Uroweb.ru by filling out a questionnaire. Results. The results obtained indicate that the most significant differences were obtained in views on the role of positron emission tomography combined with computed tomography (PET/CT) in the primary diagnosis of non-metastatic PCа and the importance of local prevalence in determining the risk of progression, while the attitude to genetic testing, primary local staging and prognosis criteria after radical prostatectomy in the majority respondents were similar. Conclusions. Most Russian oncourologists specialists involved in the treatment of PCа do not recommend that patients with PCа-HR perform PET/CT with prostate specific membrane antigen (68Ga-PSMA) and do not prescribe geneticist consultation and genetic counseling for non-metastatic PCа. To assess the local prevalence of the process in prostate cancer, based on the results of MRI, digital rectal examination and the percentage of tumor tissue in the biopsy sample. Most specialists determine the prognosis of a patient after RP by summing up the pathomorphological (PSA + radiological diagnostics + the result of histological examination) and clinical (PSA + radiological diagnostics + biopsy) indicators, which quite correlates with the global data.

The relationship between 68Ga-PSMA uptake and Gleason Score and PSA levels in patients with prostate cancer

Aim: PSMA expression has been observed in increased levels in patients with high Gleason scores. Current information on Ga-68 PSMA PET/CT shows that primary staging with PET/CT is important in patients with high-risk PC. Ga-68 PSMA PET/CT may also have a place in patients with intermediate risk PC, but only a few data are available at present. In this study, we aimed to elucidate the relationship between PSMA expression value in the prostate gland, total PSA levels and GS in patients diagnosed with prostate cancer.
 Material and Method: A total of 98 patients who were pathologically diagnosed with prostate cancer that did not receive any treatment and underwent Ga‐68 PSMA PET/CT imaging for staging were included in the study. Findings detected in Ga‐68 PSMA PET/CT imaging were categorized as prostate, lymph node, bone, and visceral organ. The focal increased PSMA expression values ​​observed in the prostate gland were recorded as SUVmax. The patients were divided into two separate groups according to their GS score (GS>7 and GS≤7). Correlations between prostate PSMA SUVmax, GS score and total PSA scores were investigated.
 Results: PSMA SUVmax levels of the group with a Gleason score of >7 were found to be significantly higher than the group with a Gleason score of ≤7 (p=0.03). The rates of lymph node metastasis, bone metastasis and visceral organ metastases were found to be significantly higher in the group with a Gleason score >7 compared to the group with a Gleason score ≤7. A positive correlation was observed between PSMA SUVmax and Total PSA (r=0.260, p=0.01). A positive correlation was observed between PSMA SUVmax and Gleason score (r=0.260, p=0.01). A positive correlation was observed between total PSA and Gleason score (r=0.320, p=0.001).
 Conclusion: In conclusion, PSMA SUVmax and Total PSA levels were higher in the group with high Gleason score. There is a positive correlation between PSMA SUVmax and total PSA. Clinicians should be careful in this regard, as the possibility of metastasis will be high in groups with high Gleason scores.

Artificial intelligence-based measurements of PET/CT imaging biomarkers are associated with disease-specific survival of high-risk prostate cancer patients

Objective Artificial intelligence (AI) offers new opportunities for objective quantitative measurements of imaging biomarkers from positron-emission tomography/computed tomography (PET/CT). Clinical image reporting relies predominantly on observer-dependent visual assessment and easily accessible measures like SUVmax, representing lesion uptake in a relatively small amount of tissue. Our hypothesis is that measurements of total volume and lesion uptake of the entire tumour would better reflect the disease`s activity with prognostic significance, compared with conventional measurements. Methods An AI-based algorithm was trained to automatically measure the prostate and its tumour content in PET/CT of 145 patients. The algorithm was then tested retrospectively on 285 high-risk patients, who were examined using 18F-choline PET/CT for primary staging between April 2008 and July 2015. Prostate tumour volume, tumour fraction of the prostate gland, lesion uptake of the entire tumour, and SUVmax were obtained automatically. Associations between these measurements, age, PSA, Gleason score and prostate cancer-specific survival were studied, using a Cox proportional-hazards regression model. Results Twenty-three patients died of prostate cancer during follow-up (median survival 3.8 years). Total tumour volume of the prostate (p = 0.008), tumour fraction of the gland (p = 0.005), total lesion uptake of the prostate (p = 0.02), and age (p = 0.01) were significantly associated with disease-specific survival, whereas SUVmax (p = 0.2), PSA (p = 0.2), and Gleason score (p = 0.8) were not. Conclusion AI-based assessments of total tumour volume and lesion uptake were significantly associated with disease-specific survival in this patient cohort, whereas SUVmax and Gleason scores were not. The AI-based approach appears well-suited for clinically relevant patient stratification and monitoring of individual therapy.

Diagnostic Accuracy of 68Ga-PSMA-11 PET for Pelvic Nodal Metastasis Detection Prior to Radical Prostatectomy and Pelvic Lymph Node Dissection

The presence of pelvic nodal metastases at radical prostatectomy is associated with biochemical recurrence after prostatectomy. To assess the accuracy of prostate-specific membrane antigen (PSMA) 68Ga-PSMA-11 positron emission tomographic (PET) imaging for the detection of pelvic nodal metastases compared with histopathology at time of radical prostatectomy and pelvic lymph node dissection. This investigator-initiated prospective multicenter single-arm open-label phase 3 imaging trial of diagnostic efficacy enrolled 764 patients with intermediate- to high-risk prostate cancer considered for prostatectomy at University of California, San Francisco and University of California, Los Angeles from December 2015 to December 2019. Data analysis took place from October 2018 to July 2021. Imaging scan with 3 to 7 mCi of 68Ga-PSMA-11 PET. The primary end point was the sensitivity and specificity for the detection pelvic lymph nodes compared with histopathology on a per-patient basis using nodal region correlation. Each scan was read centrally by 3 blinded independent central readers, and a majority rule was used for analysis. A total of 764 men (median [interquartile range] age, 69 [63-73] years) underwent 1 68Ga-PSMA-11 PET imaging scan for primary staging, and 277 of 764 (36%) subsequently underwent prostatectomy with lymph node dissection (efficacy analysis cohort). Based on pathology reports, 75 of 277 patients (27%) had pelvic nodal metastasis. Results of 68Ga-PSMA-11 PET were positive in 40 of 277 (14%), 2 of 277 (1%), and 7 of 277 (3%) of patients for pelvic nodal, extrapelvic nodal, and bone metastatic disease. Sensitivity, specificity, positive predictive value, and negative predictive value for pelvic nodal metastases were 0.40 (95% CI, 0.34-0.46), 0.95 (95% CI, 0.92-0.97), 0.75 (95% CI, 0.70-0.80), and 0.81 (95% CI, 0.76-0.85), respectively. Of the 764 patients, 487 (64%) did not undergo prostatectomy, of which 108 were lost to follow-up. Patients with follow-up instead underwent radiotherapy (262 of 379 [69%]), systemic therapy (82 of 379 [22%]), surveillance (16 of 379 [4%]), or other treatments (19 of 379 [5%]). This phase 3 diagnostic efficacy trial found that in men with intermediate- to high-risk prostate cancer who underwent radical prostatectomy and lymph node dissection, the sensitivity and specificity of 68Ga-PSMA-11 PET were 0.40 and 0.95, respectively. This academic collaboration is the largest known to date and formed the foundation of a New Drug Application for 68Ga-PSMA-11. ClinicalTrials.gov Identifiers: NCT03368547, NCT02611882, and NCT02919111.

The role of histopathological and biochemical parameters for predicting metastatic disease on 68 Ga-PSMA-11 PET in prostate cancer.

The aim of this study was to evaluate the role of histopathological and biochemical parameters in the prediction of the presence and number of PSMA positive lesions consistent with the metastatic spread of prostate cancer on 68 Ga-PSMA PET images. Biochemical, histopathological and imaging data of 302 prostate cancer patients who underwent 68 Ga-PSMA-11 PET/CT or PET/MR imaging for primary staging were retrospectively analyzed. Patients were divided into two groups as "PET positive" and "PET negative" according to the presence of pathologic extraprostatic PSMA involvement. "PET positive" patients were additionally divided into two groups: oligometastatic (1-3 metastatic lesion) and multimetastatic (>3 metastatic lesions). The mean age of patients was 66.8 ± 7.6 years. Imaging modality was PET/MR in 223 (73.8%) and PET/CT in 79 (26.2%) of patients. Total PSA, PSA density (PSAD), ALP, and tumor ratio in biopsy specimens were found to be significantly higher in "PET positive" group compared to "PET negative" group and in multimetastatic group compared to oligometastatic group. PET positivity was observed in 3.8% of the low-intermediate risk groups (ISUP 1-3 and total PSA ≤ 20 ng/ml and PSAD < 0.15 ng/ml/cc). This ratio was 46% in the high-risk group (ISUP 4-5 or total PSA > 20 ng/ml or PSAD ≥ 0.15 ng/ml/cc) with a relative risk of 12 (p < .001). The prediction models to predict the PET positivity and the presence of distant metastasis had AUCs of 0.901 and 0.925, respectively; with ALP, total PSA, and tumor ratio in needle biopsy specimen as significant independent predictors (p < .05). In this study, 68 Ga-PSMA-11 PET positivity was significantly higher in the high-risk patient group than in the low-intermediate risk groups. The prediction models used for predicting the PET positivity and the presence of distant metastasis on PET imaging were successful with high discriminatory powers. In addition to total PSA and ISUP GG, ALP and tumor ratio in biopsy specimens can be used to identify high-risk patients.

MP40-10 TESTICULAR TUMOR SIZE IS ASSOCIATED WITH NONLOCALIZED DISEASE AT DIAGNOSIS

You have accessJournal of UrologyPenile & Testicular Cancer I (MP40)1 Sep 2021MP40-10 TESTICULAR TUMOR SIZE IS ASSOCIATED WITH NONLOCALIZED DISEASE AT DIAGNOSIS Vidit Sharma, Patrick M. Lec, Katherine E. Fero, Andrew T Lenis, Joseph D. Shirk, Abhishek Venkataramana, Michael S. Leapman, Karim Chamie, Christopher S. Saigal, and Mark S. Litwin Vidit SharmaVidit Sharma More articles by this author , Patrick M. LecPatrick M. Lec More articles by this author , Katherine E. FeroKatherine E. Fero More articles by this author , Andrew T LenisAndrew T Lenis More articles by this author , Joseph D. ShirkJoseph D. Shirk More articles by this author , Abhishek VenkataramanaAbhishek Venkataramana More articles by this author , Michael S. LeapmanMichael S. Leapman More articles by this author , Karim ChamieKarim Chamie More articles by this author , Christopher S. SaigalChristopher S. Saigal More articles by this author , and Mark S. LitwinMark S. Litwin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002055.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Primary testicular tumor size >3 cm was recently added to the American Joint Commission on Cancer’s (AJCC) 8th edition as a criterion for tumor stage 1b in seminomas but not non-seminomatous germ cell tumors (NSGCTs). We analyzed the association of testicular tumor size with nonlocalized disease at diagnosis to determine if incorporating tumor size into staging improves discernment of metastatic propensity. METHODS: We queried the National Cancer Database (NCDB) for patients with testicular seminomas and NSGCTs in 2004–2016. We used fixed-effects multivariable logistic regressions to associate testicular tumor size and nonlocalized disease at diagnosis, defined as any cN+/M+/S+. Regressions adjusted for sociodemographic variables and AJCC 7th edition primary tumor stage that accounted for lymphovascular invasion (pT2) and involvement of the tunica vaginalis (pT2), spermatic cord (pT3), and scrotum (pT4). Significant associations of tumor size with nonlocalized disease were further characterized using non-linear restricted cubic splines to inform tumor size thresholds. RESULTS: Among 16,181 seminomas and 13,804 NSGCTs, 25.1% and 52.2% were nonlocalized at diagnosis, respectively (p<0.01 for difference). Figure 1A demonstrates that patients in higher tumor size deciles had a higher risk of nonlocalized disease at diagnosis for both seminomas and NSGCTs. On multivariable regression, 5 cm increases in tumor size were associated with nonlocalized disease in both seminoma (OR 2.29, 95% CI 2.13-2.47, p<0.001) and NSGCT (OR 1.75, 95% CI 1.62-1.89, p<0.001) with modest increases in area under the curve: 0.615 to 0.664 for seminoma and 0.638 to 0.662 for NSGCT. Restricted cubic splines demonstrated inflection points at about 3 cm and 4 cm for seminoma and NSGCT, respectively (Figure 1B). CONCLUSIONS: The addition of testicular tumor size to primary tumor staging modestly improves prediction of nonlocalized disease in both seminoma and NSGCTs. Our results support the inclusion of a 3 cm tumor size threshold into the primary tumor staging of seminomas and support investigations regarding the addition of a 4 cm tumor size threshold for NSGCTs. Further study is warranted using more granular datasets to verify these findings. Source of Funding: Vidit Sharma is supported by the VA HSRD fellowship © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e718-e718 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vidit Sharma More articles by this author Patrick M. Lec More articles by this author Katherine E. Fero More articles by this author Andrew T Lenis More articles by this author Joseph D. Shirk More articles by this author Abhishek Venkataramana More articles by this author Michael S. Leapman More articles by this author Karim Chamie More articles by this author Christopher S. Saigal More articles by this author Mark S. Litwin More articles by this author Expand All Advertisement Loading ...

PSMA-ligand uptake can serve as a novel biomarker in primary prostate cancer to predict outcome after radical prostatectomy

BackgroundThe prostate-specific membrane antigen (PSMA) is a relevant target in prostate cancer, and immunohistochemistry studies showed associations with outcome. PSMA-ligand positron emission tomography (PET) is increasingly used for primary prostate cancer staging, and the molecular imaging TNM classification (miTNM) standardizes its reporting. We aimed to investigate the potential of PET-imaging to serve as a noninvasive imaging biomarker to predict disease outcome in primary prostate cancer after radical prostatectomy (RP).MethodsIn this retrospective analysis, 186 primary prostate cancer patients treated with RP who had undergone a 68Ga-PSMA-11 PET up to three months prior to the surgery were included. Maximum standardized uptake value (SUVmax), SUVmean, tumor volume (TV) and total lesion (TL) were collected from PET-imaging. Moreover, clinicopathological information, including age, serum prostate-specific antigen (PSA) level, and pathological characteristics, was assessed for disease outcome prediction. A stage group system for PET-imaging findings based on the miTNM framework was developed.ResultsAt a median follow-up after RP of 38 months (interquartile range (IQR) 22–53), biochemical recurrence (BCR) was observed in 58 patients during the follow-up period. A significant association between a positive surgical margin and miN status (miN1 vs. miN0, odds ratio (OR): 5.428, p = 0.004) was detected. miT status (miT ≥ 3a vs. miT < 3, OR: 2.696, p = 0.003) was identified as an independent predictor for Gleason score (GS) ≥ 8. Multivariate Cox regression analysis indicated that PSA level (hazard ratio (HR): 1.024, p = 0.014), advanced GS (GS ≥ 8 vs. GS < 8, HR: 3.253, p < 0.001) and miT status (miT ≥ 3a vs. miT < 3, HR: 1.941, p = 0.035) were independent predictors for BCR. For stage I disease as determined by PET-imaging, a shorter BCR-free survival was observed in the patients with higher SUVmax (IA vs. IB stage, log-rank, p = 0.022).ConclusionPreoperative miTNM classification from 68Ga-PSMA-11 PET correlates with postoperative GS, surgical margin status and time to BCR. The association between miTNM staging and outcome proposes 68Ga-PSMA-11 PET as a novel non-invasive imaging biomarker and potentially serves for ancillary pre-treatment stratification.

Dual-Tracer Positron-Emission Tomography Using Prostate-Specific Membrane Antigen and Fluorodeoxyglucose for Staging of Prostate Cancer: A Systematic Review.

PSMA PET is more accurate than conventional imaging (CT/bone scan) for staging of intermediate- or high-risk prostate cancer (PCa), but 5–10% of primary tumours have low PSMA ligand uptake. FDG PET has been used to further define disease extent in end-stage castrate-resistant PCa and may be beneficial earlier in the disease course for more accurate staging. The objective of this study was to review the available evidence for patients undergoing both FDG and PSMA PET for PCa staging at initial diagnosis and in recurrent disease. A systematic literature review was performed for studies with direct, intraindividual comparison of PSMA and FDG PET for staging of PCa. Assessment for radioligand therapy eligibility was not considered. Risk of bias was assessed. 543 citations were screened and assessed. 13 case reports, three retrospective studies, and one prospective study were included. FDG after PSMA PET improved the detection of metastases from 65% to 73% in high-risk early castration-resistant PCa with negative conventional imaging (M0). Positive FDG PET was found in 17% of men with negative PSMA PET for postprostatectomy biochemical recurrence. Gleason score ≥8 and higher PSA levels predicted FDG-avid metastases in BCR and primary staging. Variant histology (ductal and neuroendocrine) was common in case reports, resulting in PSMA-negative FDG-positive imaging for 3 patients. Dual-tracer PET for PCa may assist in characterising high-risk disease during primary staging and restaging. Further studies are required to determine the additive benefit of FDG PET and if the FDG-positive phenotype may indicate a poorer prognosis.

Can Ultrasound Elastography Discriminate between Rectal Adenoma and Cancer? A Systematic Review.

Simple SummaryIt is important to obtain correct preoperative classification of rectal polyps and cancer prior to making treatment decisions but distinguishing between the two can be challenging. International societies recommend magnetic resonance imaging and endorectal ultrasound as part of the initial preoperative evaluation. The ultrasound examination can be improved by applying a tissue stiffness measurement, known as elastography. Our aim was to investigate the performance of elastography in the staging of rectal tumors. We systematically searched the literature and found six eligible studies. They all reported increased accuracy by elastography compared with ultrasound examination alone.Background: Rectal cancer is a common malignancy. Since the introduction of bowel-screening programs, the number of patients with advanced adenomas and early rectal cancer has increased. Despite improved diagnostics, the discrimination between rectal adenomas and early rectal cancer (i.e., pT1–T2) remains challenging. The purpose of this systematic review was to evaluate the diagnostic performance of endorectal ultrasound (ERUS) elastography in discriminating rectal adenomas from cancer. Method: Using PRISMA guidelines, a systematic search was performed on PubMed, Embase, and MEDLINE databases. Studies evaluating the primary staging of rectal adenomas and cancer using ERUS elastography were included. Results: Six studies were identified; three evaluated the discrimination between adenomas and cancer; two evaluated adenomas and early rectal cancer (i.e., pT1–T2); one evaluated performance on different T categories. All studies reported increased diagnostic accuracy of ERUS elastography compared to ERUS. Sensitivity, specificity and accuracy ranged 0.93–1.00, 0.83–1.00 and 0.91–1.00, respectively, when discriminating adenomas from cancer. In the differentiation between adenomas and early rectal cancer, the sensitivity, specificity and accuracy were 0.82–1.00, 0.86–1.00 and 0.84–1.00, respectively. Conclusion: Elastography increases the accuracy of ERUS and may provide valuable information on malignant transformation of rectal lesions.

Positron emission tomography with computed tomography/magnetic resonance imaging for primary staging of prostate cancer

Prostate cancer is the most common malignancy and the second leading cause of cancer-related death in men. Accurate imaging diagnosis and staging are crucial for patient management and treatment. The role of nuclear medicine in the diagnosis of prostate cancer has evolved rapidly in recent years due to the availability of hybrid imaging with radiopharmaceuticals targeting the prostate-specific membrane antigen (PSMA). Hybrid imaging provides higher diagnostic accuracy compared to conventional imaging and has a significant impact on clinical management. Numerous radiotracers have been used in clinical applications, with PSMA ligands being the most commonly used. Hybrid imaging provides higher diagnostic accuracy for lymph node and bone metastases compared to conventional imaging and has asignificant impact on clinical management. The high accuracy for primary staging in high-risk prostate cancer using PSMA ligands has led to the inclusion of PSMA positron emission tomography (PET)/computed tomography (CT) in the new German S3 guideline for primary staging of prostate cancer. The aim of this article is to provide an overview of the use of PET imaging in the primary diagnosis of prostate cancer, to present the most commonly used radiotracers, and to highlight the results of recent studies.

Cancer-specific and overall survival in African American women with endometrial cancer: a SEER-Medicare study

<h3>Objectives:</h3> To compare the overall survival (OS) and cancer specific survival (CSS) by race for women with stage I-III endometrial cancer (EC) by histologic subtype. <h3>Methods:</h3> This is a retrospective cohort study of women with stage I-III endometrioid, serous, clear cell, and carcinosarcoma who underwent hysterectomy as primary surgical staging as identified within the SEER-Medicare database. Endometrial cancer cases diagnosed between 2000 and 2015 with Medicare enrollment data from 1999-2016 were included. Demographics, cancer data, and survival outcomes were collected. Demographic and treatment factors by race were compared using descriptive analyses. OS and CSS outcomes were stratified by race, stage and histology, then analyzed using log rank tests and multivariate cox modeling (adjusting for age, geographic region, Charlson comorbidity index, post-operative treatment sequencing, FIGO stage, and grade). <h3>Results:</h3> 24,142 total patients were included in this dataset. 85.5% were White, and 8.5% were BlackBlack. 19,351 stage I, 1,484 stage II, and 3,307 stage III cases were identified. Black women were diagnosed at a younger age bracket (40-69yo) than White patients for endometrioid stage I (40% vs 35%), II (37% vs 31%), and III (31% vs 28%); serous stage I (45% vs 31%) and III (42% vs 28%), and carcinosarcoma stage I (39% vs 27%), p<0.05 all. Charlson comorbidity indexes were significantly higher for BlackBlack patients with endometrioid stages I (p<0.001), II (p=0.001), and III (p=0.02) and serous stage I (p<0.0001) and III (p=0.02). Receipt of adjuvant therapy did not differ by race for any stage or histology except for stage III endometrioid where Black women were less likely to receive adjuvant treatment (61.2% vs 70.1% White p=0.03). For stage I, BlackBlack patients had worse CSS and OS for all histologies except clear cell in unadjusted and adjusted analyses (Table I). For stage II, only CSS for endometrioid carcinoma differed by race in unadjusted analyses, whereas OS did not. For stage III, BlackBlack patients with endometrioid carcinoma had worse CSS and OS in unadjusted analyses, but significant survival differences only remained for CSS in the adjusted model. <h3>Conclusions:</h3> Prior studies have reported that BlackBlack women with endometrial cancer have worse survival consistently across stage and histology. However, we did not find this effect when evaluating by CSS and OS. For stage I, BlackBlack women had consistently worse CSS likely related to the disease itself and worse OS in adjusted analyses likely related to poorer overall health outcomes across all histologic subtypes except for clear cell. For stage II and III, racial disparities were seen only for CSS in endometrioid patients in the adjusted analyses, but not OS; and this may have been related to BlackBlack women with stage III cancer receiving less adjuvant therapy. When stratified by stage and histology, BlackBlack women with EC were diagnosed at younger age and with more comorbidities. Overall these findings emphasize the need to intervene in the early stage population, where a disparity exists and the largest population of women is affected.

Clinical aspects in the diagnosis and treatment of prostate cancer

Diagnosis and treatment of primary prostate cancer (PCA) have undergone significant changes in the last few years due to modern imaging. Established and modern diagnostic and therapeutic modalities for detection and treatment of primary PCA are presented and discussed critically. Background knowledge and guideline recommendations on primary PCA are summarized and additional information from relevant publications is given. Modern imaging, in particular multiparametric magnetic resonance imaging (mpMRI), has revolutionized the diagnostic work-up of primary PCA. Due to mpMRI, tumors are detected significantly better in both initial and re-biopsy with asignificant reduction of overdiagnosis of clinically insignificant PCA. Therapeutic approaches such as active surveillance, radical prostatectomy and focal therapies are increasingly being planned and carried out relying on MR-imaging information concerning tumor extent and tumor aggressiveness. In addition, prostate-specific membrane antigen-positron emission tomography/computed tomography (PSMA-PET/CT) has shown superiority in assessing patients with suspected biochemical recurrence and in primary staging of PCA compared to conventional imaging in terms of detection of metastases. Modern imaging, especially mpMRI and PSMA-PET/CT, has added substantial benefits in modern diagnosis and treatment of primary PCA. Moreover, multiparametric ultrasound is also apromising addition to the radiological armamentarium in the management of primary PCA.

Role of PET/computed tomography and biopsy guidance in characterization of malignant biliary obstruction

Objective This prospective study was conducted to evaluate the diagnostic effect of PET/computed tomography (PET/CT) in patients with malignant biliary obstruction and if the metabolic information provided by PET/CT scan adds an incremental benefit while performing image-guided biopsies. Background Malignant biliary tract obstruction is a frequent cause of jaundice. PET/CT is used to evaluate such patients, and information delivered by PET images is used to guide biopsy procedure. Patients and methods This study was carried out from March 2016 to March 2018 on 52 patients diagnosed/suspected to have MTBO. They all were investigated by PET/CT. Results were compared with the results of contrast-enhanced CT in ∼42 cases and with magnetic resonance cholangiopancreatography (MRCP) in ∼15 cases. A group of patients had undergone PET/CT-guided biopsy (15 patients). Results This study revealed that sensitivity, specificity, positive predictive value, and negative predictive value for PET/CT were 92, 75, 96, and 60%, respectively, whereas for CT and for MRCP were 68, 60, 85, and 20% and 60, 50, 85, and 20%, respectively. PET/CT has sensitivity of 90% for detection of lymph nodal metastases compared with 37% for CT and 20% for MRCP. PET/CT is more sensitive than CT and MRCP for distant metastases detection. Conclusion PET/CT is more sensitive and specific than CT and MRCP in primary detection and staging of tumors causing malignant biliary tract obstruction. PET/CT-guided biopsy increases the chance of obtaining a definitive diagnostic result.

Clinical practice guidelines for hepatocellular carcinoma between Korea, Europe, and United States

Clinical practice guidelines for hepatocellular carcinoma between Korea, Europe, and United States