8506 Background: We published a pooled analysis of 2 randomized trials (STARS/ROSEL) that compared lobectomy with mediastinal lymph node dissection (L-MLND) vs stereotactic ablative radiotherapy (SABR) in operable stage I NSCLC. There were no significant differences in disease progression but significantly higher 3-year overall survival (OS) in the SABR arm (95% vs 79%). Owing to concerns regarding the small sample size (n = 58), short follow-up (3 years), and non-uniform use of video-assisted thoracoscopic surgery (VATS), we expanded the STARS protocol to a single-arm SABR trial with a protocol-specified comparison to a published, longitudinally-followed institutional cohort of stage IA NSCLC status post VATS L-MLND (n = 229). Methods: Inclusion criteria were stage IA NSCLC (≤3 cm, N0M0 and staged by PET/CT with EBUS) with Zubrod performance status (PS) 0-2, baseline FEV1 > 40% and DLCO > 40% and deemed operable by a multidisciplinary team. SABR utilized 4-dimensional CT simulation and volumetric image guidance; 54 Gy in 3 fractions were delivered to planning target volumes (PTVs) located peripherally, or 50 Gy in 4 fractions to more central PTVs. All patients were followed by chest CT every three months for the first two years, every 6 months for another three years, and then annually. Non-inferiority of SABR could be claimed if the 3-year OS was not lower than the historical VATS L-MLND cohort by more than 12%. We conducted a risk-factor matched comparison study of the primary outcome between the SABR and the historical VATS L-MLND. Results: The median follow-up among the 80 SABR patients was 61 months (range, 34-79 months). The OS and progression-free survival (PFS) were 91% (95% CI: 85̃98%) and 80% (95% CI: 72̃89%) at 3 years, and 87% (95% CI: 79̃95%) and 77% (95% CI: 68̃87%) at 5 years, respectively. The 5-year cumulative incidence rate counting death as competing risk was 6.3% (95% CI: 2.3̃13.2%) local, 12.5% (95% CI: 6.4̃20.8%) regional, and 8.8% (95% CI: 3.8̃16.2%) distant (any recurrence 17.6% (95% CI: 10.1̃26.7%)). The 5 year cumulative incidence rate of second lung primary was 6.9% (95% CI: 2.5̃14.6%). There were 1.3% grade 3 and no grade 4-5 toxicities. The propensity score matched (age, gender, tumor size, histology, PS) comparison of SABR vs VATS L-MLND revealed no significant differences in PFS (p = 0.063), lung cancer-specific survival (p = 0.075), or cumulative incidence rates of local (p = 0.54), regional (p = 0.97), or distant failures (p = 0.33). The SABR arm was associated with significantly higher OS (91% vs 82% at 3 years and 87% vs 72% at 5 years; p = 0.012 from log-rank test). The hazard ratio was 0.411 (95% CI: 0.193̃0.875; p = 0.021). Conclusions: The long-term OS and PFS of SABR is not inferior to VATS L-MLND for operable stage IA NSCLC. SABR remains a promising approach for this population, but multidisciplinary management is strongly recommended. Clinical trial information: NCT02357992.

To report long-term follow-up of the efficacy of subtotal prostate ablation using a “hockey-stick” template, including oncologic control and quality of life (QoL) impact. We performed a prospective controlled trial to evaluate the efficacy of subtotal prostate ablation in selected men with baseline and confirmatory biopsy showing grade group (GG) 1–2 prostate cancer. “Hockey-stick” cryoablation that included the ipsilateral hemi-gland and contralateral anterior prostate was performed. Prostate biopsies and QOL queries were performed at 6, 18 and 36 months following regional ablation, and follow-up was updated to include subsequent clinic visits. Between August 2009 and January 2012, 72 men were screened for eligibility and 47 opted to undergo confirmatory biopsy. Of these, 23 were deemed eligible and treated with regional cryoablation. Median age was 64 years. Median follow-up was 74 months. A single patient had < 1 mm of in-field viable tumor with therapy effect on 36-month biopsy. At time of last follow-up, a total of 12/23 (52%) patients did not have evidence of disease, all patients had preserved urinary control with no patients requiring pads for urinary incontinence. Sexual decline was significant at 3 and 6 months (P < 0.01 for both), though improvement was seen at subsequent time points. Subtotal (hockey-stick template) cryoablation of the prostate provides oncologic control to targeted tissue in a generally low-risk group with minimal impact on sexual and urinary function. Further studies are needed to evaluate this ablation template in the MRI-targeted era and higher risk populations.

Background A previous pooled analysis of the STARS and ROSEL trials showed higher survival after stereotactic ablative radiotherapy (SABR) than with surgery for operable early-stage non-small-cell lung cancer (NSCLC), but that analysis had notable limitations. This study reports long-term results of the revised STARS trial, in which the SABR group was re-accrued with a larger sample size, along with a protocol-specified propensity-matched comparison with a prospectively registered, contemporary institutional cohort of patients who underwent video-assisted thoracoscopic surgical lobectomy with mediastinal lymph node dissection (VATS L-MLND). Methods This single-arm prospective trial was done at the University of Texas MD Anderson Cancer Center (Houston, TX, USA) and enrolled patients aged 18 years or older with a Zubrod performance status of 0-2, newly diagnosed and histologically confirmed NSCLC with N0M0 disease (squamous cell, adenocarcinoma, large cell, or NSCLC not otherwise specified), and a tumour diameter of 3 cm or less. This trial did not include patients from the previous pooled analysis. SABR dosing was 54 Gy in three fractions (for peripheral lesions) or 50 Gy in four fractions (for central tumours; simultaneous integrated boost to gross tumour totalling 60 Gy). The primary endpoint was the 3-year overall survival. For the propensity-matching analysis, we used a surgical cohort from the MD Anderson Department of Thoracic and Cardiovascular Surgery's prospectively registered, institutional review board-approved database of all patients with clinical stage I NSCLC who underwent VATS L-MLND during the period of enrolment in this trial. Non-inferiority could be claimed if the 3-year overall survival rate after SABR was lower than that after VATS L-MLND by 12% or less and the upper bound of the 95% CI of the hazard ratio (HR) was less than 1middot965. Propensity matching consisted of determining a propensity score using a multivariable logistic regression model including several covariates (age, tumour size, histology, performance status, and the interaction of age and sex); based on the propensity scores, one patient in the SABR group was randomly matched with one patient in the VATS L-MLND group using a 5:1 digit greedy match algorithm. This study is registered with ClinicalTrials.gov, NCT02357992. Findings Between Sept 1, 2015, and Jan 31, 2017, 80 patients were enrolled and included in efficacy and safety analyses. Median follow-up time was 5middot1 years (IQR 3middot9-5middot8). Overall survival was 91% (95% CI 85-98) at 3 years and 87% (79-95) at 5 years. SABR was tolerated well, with no grade 4-5 toxicity and one (1%) case each of grade 3 dyspnoea, grade 2 pneumonitis, and grade 2 lung fibrosis. No serious adverse events were recorded. Overall survival in the propensity-matched VATS L-MLND cohort was 91% (95% CI 85-98) at 3 years and 84% (76-93) at 5 years. Non inferiority was claimed since the 3-year overall survival after SABR was not lower than that observed in the VATS L-MLND group. There was no significant difference in overall survival between the two patient cohorts (hazard ratio 0middot86 [95% CI 0middot45-1middot65], p=0middot65) from a multivariable analysis. Interpretation Long-term survival after SABR is non-inferior to VATS L-MLND for operable stage IA NSCLC. SABR remains promising for such cases but multidisciplinary management is strongly recommended. Funding Varian Medical Systems and US National Cancer Institute (National Institutes of Health). Copyright (c) 2021 Elsevier Ltd. All rights reserved.

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy II (MP70)1 Apr 2020MP70-14 PROSPECTIVE TRIAL OF REGIONAL (HOCKEY-STICK) PROSTATE CRYOABLATION: 7-YEAR PATHOLOGIC AND QUALITY OF LIFE OUTCOMES Leonardo Borregales*, Justin Gregg, Haesun Choi, Marisa Lozano, Stephen McRae, Aradhana Venkatesan, Graciela Nogueras Gonzalez, John Davis, Louis Pisters, and John Ward Leonardo Borregales*Leonardo Borregales* More articles by this author , Justin GreggJustin Gregg More articles by this author , Haesun ChoiHaesun Choi More articles by this author , Marisa LozanoMarisa Lozano More articles by this author , Stephen McRaeStephen McRae More articles by this author , Aradhana VenkatesanAradhana Venkatesan More articles by this author , Graciela Nogueras GonzalezGraciela Nogueras Gonzalez More articles by this author , John DavisJohn Davis More articles by this author , Louis PistersLouis Pisters More articles by this author , and John WardJohn Ward More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000950.014AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Organ preserving therapies are of particular interest in the treatment of localized prostate cancer (PC) with a goal of decreasing morbidity associated with radical treatment while maintaining oncologic control. With the development of Index Tumor theory of PC in parallel with improved ablative technology, regional ablation of PC has become an intriguing concept. We report long term follow-up of a prospective clinical trial of subtotal prostate ablation (hockey-stick template), including oncologic efficacy and quality of life (QoL) impact. METHODS: Men with low and intermediate risk PC by systematic diagnostic biopsy was performed. All men underwent confirmatory 12-core, extended scheme biopsy using robotic assistance to eliminate user bias, standardize the biopsy across the study’s time course and minimize sampling bias. Men were eligible to proceed with regional cryoablation if confirmatory biopsy revealed grade group (GG) 1 or 2 disease in fewer than 50% of unilateral cores and no more than 50% involvement of any single core. Contralateral GG1 with <2mm involvement was also eligible. EPIC QoL questionnaires were completed prior to confirmatory biopsy and at each follow-up visit. Prostate biopsies were performed in a similar fashion at 6, 18 and 36 months following regional ablation, and follow-up was updated to include subsequent visits. RESULTS: Between August 2009 and January 2012, 72 men were screened for trial eligibility and 47 underwent confirmatory biopsy, of whom 23 were treated with regional cryoablation. Median age at the time of treatment was 63 years. A single patient had <1mm of in-field tumor with therapy effect on 36 month biopsy. Total median follow-up was 74 months.During this time, new out-of field GG1 cancer was discovered on subsequent biopsies in 9 patients. Out of these, 1 patient opted for radiation therapy, 1 patient underwent re-do cryoablation while 7 others continued on active surveillance without subsequent GG increase. A total of 12 (52%) patients did not have evidence of disease, all patients had preserved urinary control with 0% of patients requiring pads for incontinence and sexual function decline was less than 20% of baseline. CONCLUSIONS: Focal (hockey-stick template) cryoablation of the prostate provides excellent oncologic efficacy to targeted tissue with minimal impact on sexual and urinary function in well selected patients. This feasibility study can be used to justify further investigations into organ preserving PC ablative techniques using improved imaging and a variety of thermal energy sources. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1060-e1060 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leonardo Borregales* More articles by this author Justin Gregg More articles by this author Haesun Choi More articles by this author Marisa Lozano More articles by this author Stephen McRae More articles by this author Aradhana Venkatesan More articles by this author Graciela Nogueras Gonzalez More articles by this author John Davis More articles by this author Louis Pisters More articles by this author John Ward More articles by this author Expand All Advertisement PDF downloadLoading ...

Despite the establishment of uterine fibroid embolization (UFE) as a safe and effective treatment option for uterine leiomyomata, the real-world utilization and outcomes of UFE relative to surgical techniques are unknown. The purpose of this study was to conduct a population level analysis for the treatment of uterine leiomyomata by UFE, myomectomy, and hysterectomy. Using administrative data from all outpatient hospital encounters in California (2005 – 2011) and Florida (2005 – 2014), we identified all patients in the ambulatory surgery setting with uterine leiomyomata based on the relevant ICD-9 diagnostic codes. Patient demographics as well as intervention procedure volume and costs were analyzed. Within a cohort of 227,489 patients with uterine leiomyomata, a total of 39.9% (90,800/227,489) patients underwent hysterectomy, myomectomy, or UFE. In 2005, the distribution of procedural volume was as follows: hysterectomy 48.6%, myomectomy 31.5%, UFE 19.9%. Since 2005, the proportion of patients undergoing outpatient hysterectomy has increased; in 2011, the distribution of procedure volume was as follows: hysterectomy 72.5%, myomectomy 18.8%, UFE 8.6%. Mean length of stay following hysterectomy was significantly longer (0.5 days) compared to myomectomy (0.2 days) and UFE (0.3 days) (P < 0.001 for both). The mean hospital charges for UFE ($22,850) were significantly less compared to both hysterectomy ($40,190) and myomectomy ($29,760). Of the 7,189 patients who underwent UFE during the study period, 3.7% underwent subsequent hysterectomy. The proportion of women treated with hysterectomy in an outpatient setting has increased since 2005 despite a significant higher cost and hospitalization compared to less invasive methods. UFE may be an underutilized treatment option for patients with uterine leiomyomata.Tabled 1Hysterectomy (Open or Laparoscopic)MyomectomyUFEAge (median)4639.645Ethnicity White57.4%48.2%37% Black19.3%*27.9%**42.8%*,** Hispanic18.2%19.2%12.8%Insurance Medicaid4.8%3.8%5.3% Private82.6%87.6%84.5% Self-pay1.1%2.2%1.9%Length of stay (mean days, [range])0.5 [0 – 3]*,**0.21 [0 – 3]*0.3 [0 – 3]**Mean hospital charges, $40,190*29,760**22,850*,***,** P < 0.001. Open table in a new tab

Percutaneous biopsy of retroperitoneal lesions via a transcaval approach has historically not been a preferred means of access secondary to concern for bleeding complications. The purpose of this study is to examine the safety and diagnostic adequacy of transcaval biopsies. 31 patients with clinical follow up underwent percutaneous transcaval biopsy of a retroperitoneal node using coaxial technique. Biopsies were performed with 22G fine needle aspiration (31/31) with or without additional 20G core biopsy (5/31). Clinical, imaging, and laboratory variables were analyzed, including position of guide needle with respect to the cava. Technical success was achieved in 100% of cases. Biopsies were diagnostic in 25/31 patients (80%). 24 (77%) cases were performed with FNA only and with pre-caval guide position, and 7 (23%) were performed with post-caval guide position (through both walls of the cava). There was no significant difference between pre- and post-caval guide positions on rate of diagnostic success (p=0.9) or change in hemoglobin levels (p=1.0). Flow cytometry was able to be performed in 4/7 (57%) cases in patients with history of non-Hodgkin's Lymphoma. There was 1 complication (3%) of post-biopsy retroperitoneal hemorrhage without hemodynamic changes in the pre-caval group which was managed conservatively. Percutaneous transcaval coaxial biopsy of retroperitoneal lesions is a safe and effective diagnostic technique with a low rate of post-procedural complications and a high rate of diagnostic adequacy of samples gathered. Position of guide needle in coaxial technique affects neither success of biopsy nor complication rate.

You have accessJournal of UrologyProstate Cancer: Detection & Screening VII1 Apr 2018MP82-11 COMPARATIVE OUTCOMES AFTER 4 DIFFERENT PROSTATE BIOPSY TECHNIQUES: A FOCUS ON STANDARDIZED COMPLICATION REPORTING Cihan Demirel, Muammer Altok, John Ward, Stephen McRae, Mary Achim, and John Davis Cihan DemirelCihan Demirel More articles by this author , Muammer AltokMuammer Altok More articles by this author , John WardJohn Ward More articles by this author , Stephen McRaeStephen McRae More articles by this author , Mary AchimMary Achim More articles by this author , and John DavisJohn Davis More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2739AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Given the increased number of choices for performing a prostate biopsy, we recently reported an analysis of the cost implications, with the key findings (compared to reference transrectal ultrasound [TRUS] biopsy under local anesthesia): TRUS/IV sedation = 1.9x more expensive, transperineal (TP)/general anesthesia 2.5x, MRI-Fusion/IV sedation 2.5x, and In-Bore-MRI/IV sedation = 2.3x. In this study, we captured a representative sample of these cases to add the important layer of complication rates, as they add to the total cost. METHODS At a single tertiary care center, we retrospectively reviewed prostate biopsies from any of these modalities between 2014 and 2017. Downstream complication reporting was abstracted from hospital (combined inpatient, emergency center, clinic) and patient correspondence for the up to 90 days from procedure. Events were classified using the Clavien system. RESULTS Table 1 shows the results from 1,589 biopsies searched. Overall, TP had the highest rate of complications at 14.1% compared to <7 % for TRUS and MRI-Fusion (P <0.05). This was mostly driven by higher rates of urinary retention/catheterization. There was no statistical difference among TRUS, Fusion and In-Bore biopsies. In-Bore MRI had the lowest complication rate. Core counts were different at 24-32 for TP, 15-18 for MRI-Fusion, 12 for TRUS, and 2 for In-Bore. Urosepsis rates (with hospitalization) were 0% for TP, 0.6% for TRUS, 0.56% for MRI-fusion, and 0 for MRI In-Bore. CONCLUSIONS In addition to variant cost implications from differential use of anesthesia, number of specimens, and billing codes, complication incidence can affect overall value of a biopsy technique choice. These events can be translated in medicare allowable charges for comparison/inclusion to estimate the cost impact of complications managed in the hospital, emergency center, or clinic. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1110 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Cihan Demirel More articles by this author Muammer Altok More articles by this author John Ward More articles by this author Stephen McRae More articles by this author Mary Achim More articles by this author John Davis More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

To determine the incidence of delayed chest tube placement in patients with a stable, small pneumothorax (PTX) after outpatient CT-guided percutaneous lung biopsy (CTLB). Retrospective review of 501 consecutive patients undergoing outpatient CTLB from January 2017 – June 2017 was undertaken. Per departmental policy, single-view frontal chest x-rays (CXR) were obtained immediately and 3-hours post-biopsy. If PTX was discovered on routine CXR, a 1-hour follow-up CXR was additionally obtained. Patients with stable, small PTX were discharged after observation. Next-day CXR was ordered by the interventional radiologist who performed the CTLB. Demographics, procedure and imaging variables, and complications were collected. The average patient age was 66 years (15 – 93), 50.7% were female, and 17.4% had history of COPD. Median lesion size was 1.5 cm (0.5 – 10.0). Biopsy was performed with core in 98.2% and fine-needle aspiration in 54.5% of patients with a median 20-gauge (18 – 20) needle and 22-gauge needle, respectively. Biosentry™ tract sealant was used in 59.3% of cases. On the day of the biopsy, 104 patients (20.8%) developed PTX and 35 patients (7.0%) required chest tube. 69 patients (13.8%) were discharged with a stable, small PTX and 36/69 (52.2%) patients were scheduled for next-day CXR. Of patients returning for CXR, 32/36 (88.9%) required no intervention while 4/36 (11.1%) had an enlarging PTX needing chest tube placement. The 33/69 (47.8%) patients not returning for next-day CXR did not have a chest tube placed at our institution per the medical record; it is unknown if they needed a chest tube elsewhere. Of patients discharged with a stable, small PTX after outpatient CTLB, 52.2% underwent next-day CXR and 11.1% of them required chest tube placement, demonstrating the appropriateness of next-day follow-up in patients with stable PTX after outpatient CTLB.

Background The cornerstone of prostate cancer diagnosis remains the transrectal ultrasound-guided biopsy (TRUS-BX), which most frequently occurs in the office setting under local anesthesia. However, there are now other techniques of prostate biopsy aimed at improving outcomes such as patient comfort, significant cancer detection, and infectious complications. The purpose of the present study is to compare the cost and efficacy outcomes of five different approaches. Methods We compared the comprehensive costs of a random sample size of 20−30 cases from each of the following: (1) local anesthesia TRUS-BX (reference), (2) sedation TRUS-BX, (3) general anesthesia transperineal template biopsy (TP), (4) sedation MRI-TRUS fusion biopsy (FB), and (5) sedation in-bore MRI biopsy (IB-MRI). Cost categories included pre-procedure, anesthesia pharmacy and recovery, and the technical/professional costs from urology, radiology, and pathology services. For procedure outcomes, we compared the larger cohorts of TRUS-BX, TP, and FB in terms of indication, cancer yield, and downstream decision impact. Results Compared with standard TRUS-BX, the total costs of sedation TRUS-BX, TP, FB, and IB-MRI increased significantly ×1.9 (90%), ×2.5 (153%), ×2.5 (150%), and ×2.2 (125%), respectively ( p < 0.001). Although there was no statistical difference between the total costs of TP, FB, and IB-MRI, these costs were significantly higher than those of TRUS-BX under either local anesthesia or sedation ( p < 0.05). The cost of TRUS-BX under sedation was significantly higher than that of TRUS-BX under local anesthesia ( p < 0.001). Compared to TRUS-BX, more significant cancers were detected in FB (16% vs. 36%) and TP (16% vs. 34%) groups ( p < 0.001). Conclusions Compared with standard TRUS-BX, the additions of imaging, sedation anesthesia, and transperineal template increase costs significantly, and can be considered along with known improvements in accuracy and side effects. Ongoing efforts to combine imaging and transperineal biopsy, especially in an outpatient/local anesthesia setting may lead to a higher cost/benefit.

AbstractPercutaneous image-guided biopsy of the pancreas is a safe, effective, efficient, and minimally invasive way to obtain samples for pathological diagnosis of pancreatic mass lesions. The myriad of diseases that can involve the pancreas require different therapies. Therefore, pathological diagnosis is key. With proper imaging resources and techniques, most mass lesions of the pancreas that are visible on cross-sectional imaging can be approached safely and accurately percutaneously under either computed tomography (CT) or ultrasound guidance. These lesions may be accessed through anterior, posterior, and/or lateral approaches depending upon their proximity to the anticipated skin puncture site, and the presence or absence of intervening structures. While the ideal percutaneous route to any pancreatic target lesion is the one that has no vital structures in its path, methods and tools exist to make even the most seemingly obstructed paths to pancreatic targets navigable. Once accessed, the targets may be sampled by either fine-needle aspiration or core needle biopsy. The alternatives to percutaneous image-guided biopsy of the pancreas include open (surgical) biopsy and endoscopic ultrasound-guided (EUS) biopsy. Percutaneous image-guided biopsy poses less risk to the patient than open biopsy and has been shown to be as accurate as EUS biopsy with an even lower complication rate.

To describe the technique and results of MRI-guided transgluteal prostate biopsy performed in a closed MRI on a select group of patients, and to demonstrate the feasibility, safety, and clinical utility of this approach. 47 men (average age of 61 years, range 41-77) were referred for prostate MRI and subsequently transgluteal MR-guided prostate biopsy. The referrals fell into three general categories: (A) patients with prior transrectal ultrasound (TRUS) biopsies showing prostate cancer referred for re-evaluation due to discordant PSA levels (PSA out of proportion relative to Gleason) (n = 25 of 47); (B) patients with one or more (range 1 to 4) prior negative TRUS biopsies and discordant PSA levels (n = 15 of 47); and (C) patients with a history of total prostatectomy ± colectomy, i.e. not amenable to TRUS, and suspicion of disease recurrence based on PSA. All patients received pre-procedure multiparametric diagnostic MRI which included dynamic contrast enhanced imaging, T2 sequencing, and diffusion weighted imaging. Only patients with suspicious focal findings on MRI were referred for MRI-guided biopsy. A safe transgluteal route to the area of interest was determined. Only one to two lesions were targeted per patient. All biopsies were technically successful, as defined by satisfactory image confirmation of targeting, and all were without immediate complication. 23 (49%) of the biopsies returned a diagnosis of prostate cancer. 15 (32%) had upgrading of previously biopsy proven prostate cancer. 7(15%) patients had prior negative prostate biopsies and were diagnosed with clinically significant (Gleason 4 + 3 or higher) prostate cancer. 22(47%) of patients were transitioned from watchful waiting to definitive therapy (Surgery, Radiation and/or Medicinal) by the referring urologist as a result of positive findings on MRI-guided biopsy. The clinical utility of the MR-guided transgluteal biopsy is manifest in its ability to diagnose new cancers and upgrade previously diagnosed cancers of the prostate, thereby allowing a significant number of patients to transition from watchful waiting and active surveillance to more definitive therapy.

PURPOSE:To evaluate the use of a self-expanding tract sealant device (BioSentry™) on the rates of pneumothorax and chest tube insertion after percutaneous lung biopsy. MATERIALS AND METHODS:In this retrospective study, we compared 318 patients who received BioSentry™ during percutaneous lung biopsy (treated group) with 1956 patients who did not (control group). Patient-, lesion-, and procedure-specific variables, and pneumothorax and chest tube insertion rates were recorded. To adjust for potential selection bias, patients in the treated group were matched 1:1 to patients in the control group using propensity score matching based on the above-mentioned variables. Patients were considered a match if the absolute difference in their propensity scores was ≤equal to 0.02. RESULTS:Before matching, the pneumothorax and chest tube rates were 24.5 and 13.1% in the control group, and 21.1 and 8.5% in the treated group, respectively. Using propensity scores, a match was found for 317 patients in the treatment group. Chi-square contingency matched pair analysis showed the treated group had significantly lower pneumothorax (20.8 vs. 32.8%; p = 0.001) and chest tube (8.2 vs. 20.8%; p < 0.0001) rates compared to the control group. Sub-analysis including only faculty who had >30 cases of both treatment and control cases demonstrated similar findings: the treated group had significantly lower pneumothorax (17.6 vs. 30.2%; p = 0.002) and chest tube (7.2 vs. 18%; p = 0.001) rates. CONCLUSIONS:The self-expanding tract sealant device significantly reduced the pneumothorax rate, and more importantly, the chest tube placement rate after percutaneous lung biopsy.

To describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for renal artery embolization following partial nephrectomy and to study its relationship to RENAL nephrometry scores.

Selective transarterial embolization for liver neoplasms is performed with the aim to improve treatment efficacy and minimize adverse events. Selective catheterization of the hepatic arteries supplying the target tumor is sometimes challenging or even impossible. Temporary balloon occlusion techniques have been used successfully to redirect the flow of blood and embolic material during transarterial procedures ( 1 Nakamura H. Tanaka M. Oi H. Hepatic embolization from the common hepatic artery using balloon occlusion technique. AJR Am J Roentgenol. 1985; 145: 115-116 Crossref PubMed Scopus (20) Google Scholar , 2 Todoroki W. Hirakawa M. Nagao E. Soeda H. Tsuruta S. Honda H. Transarterial chemoembolization for hepatocellular carcinoma using a new double-lumen microballoon catheter with a side hole. J Vasc Interv Radiol. 2014; 25: 1485-1486 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar , 3 Matsumoto T. Endo J. Hashida K. et al. Balloon-occluded transarterial chemoembolization using a 1.8-French tip coaxial microballoon catheter for hepatocellular carcinoma: technical and safety considerations. Minim Invasive Ther Allied Technol. 2015; 24: 94-100 Crossref PubMed Scopus (26) Google Scholar , 4 Pierot L. Cognard C. Spelle L. Moret J. Safety and efficacy of balloon remodeling technique during endovascular treatment of intracranial aneurysms: critical review of the literature. AJNR Am J Neuroradiol. 2012; 33: 12-15 Crossref PubMed Scopus (156) Google Scholar ). We describe a balloon occlusion technique applied to facilitate selective catheterization of the small left and middle hepatic arteries during bland embolization in a patient with a gastrointestinal stromal tumor hepatic metastasis.

In order to accurately assess positioning errors in spinal SBRT, many institutions employ bony-fusion based imaging techniques, such as the ExacTrac™ (Brain Lab) system, in conjunction with 3D verification (performed via CT-on-rails in our practice). We hypothesized that the use of implanted gold fiducial markers could improve the accuracy of patient positioning over bony fusion alone. We addressed this question prospectively, enrolling patients on an IRB-approved protocol. Gold seeds were implanted in the vertebral pedicles flanking the target level. At treatment, setup error was calculated using two methods-standard kV image fusion, and geometric fiducial-based projection, with independent CT-on-rails verification. Analyses of residual set-up error showed that fiducial-based setup agreed with fusion-based determination, but did not significantly reduce error. Offline 6D fusion of the treatment and planning CT illustrated residual rotational error using standard or fiducial based setup. We conclude that the ExacTrac and CT-on-rails platform yields highly accurate results for spinal SBRT setup, with reduced residual error than previously reported. While the addition of fiducials did not further reduce error, the bony fusion approach is now prospectively validated in comparison to implanted fiducials. Both bony fusion and fiducial marker methods are associated with residual rotational error, thus 3D verification remains an important component of spinal SBRT treatment.

Background The standard of care for operable, stage I, non-small-cell lung cancer (NSCLC) is lobectomy with mediastinal lymph node dissection or sampling. Stereotactic ablative radiotherapy (SABR) for inoperable stage I NSCLC has shown promising results, but two independent, randomised, phase 3 trials of SABR in patients with operable stage I NSCLC (STARS and ROSEL) closed early due to slow accrual. We aimed to assess overall survival for SABR versus surgery by pooling data from these trials.Methods Eligible patients in the STARS and ROSEL studies were those with clinical T1-2a (<4 cm), N0M0, operable NSCLC. Patients were randomly assigned in a 1:1 ratio to SABR or lobectomy with mediastinal lymph node dissection or sampling. We did a pooled analysis in the intention-to-treat population using overall survival as the primary endpoint. Both trials are registered with ClinicalTrials. gov (STARS: NCT00840749; ROSEL: NCT00687986).Findings 58 patients were enrolled and randomly assigned (31 to SABR and 27 to surgery). Median follow-up was 40.2 months (IQR 23.0-47.3) for the SABR group and 35.4 months (18.9-40.7) for the surgery group. Six patients in the surgery group died compared with one patient in the SABR group. Estimated overall survival at 3 years was 95% (95% CI 85-100) in the SABR group compared with 79% (64-97) in the surgery group (hazard ratio [HR] 0.14 [95% CI 0.017-1.190], log-rank p= 0.037). Recurrence-free survival at 3 years was 86% (95% CI 74-100) in the SABR group and 80% (65-97) in the surgery group (HR 0.69 [95% CI 0.21-2.29], log-rank p= 0.54). In the surgery group, one patient had regional nodal recurrence and two had distant metastases; in the SABR group, one patient had local recurrence, four had regional nodal recurrence, and one had distant metastases. Three (10%) patients in the SABR group had grade 3 treatment-related adverse events (three [10%] chest wall pain, two [6%] dyspnoea or cough, and one [3%] fatigue and rib fracture). No patients given SABR had grade 4 events or treatment-related death. In the surgery group, one (4%) patient died of surgical complications and 12 (44%) patients had grade 3-4 treatment-related adverse events. Grade 3 events occurring in more than one patient in the surgery group were dyspnoea (four [15%] patients), chest pain (four [15%] patients), and lung infections (two [7%]).Interpretation SABR could be an option for treating operable stage I NSCLC. Because of the small patient sample size and short follow-up, additional randomised studies comparing SABR with surgery in operable patients are warranted.

Purpose Describe the technique and results of transgluteal MR-guided (TGMR) prostate biopsy. Compare the TGMR approach to other approaches. Materials and Methods 10 men (average age 59 years, range 44-71) had TGMR prostate biopsy. 4 men (40%) had a prior transrectal US-guided (TRUS) biopsy showing prostate cancer, 5 men (50%) had prior negative TRUS biopsies (range 1-3 biopsies), 1 patient (10%) had history of total colectomy and had prior negative transurethral and transgluteal CT-guided biopsies. Average PSA before biopsy was 11.7 (range 4.7-30.2). All patients had diagnostic prostate MRI showing a suspicious area before biopsy. The procedures were done with general anesthesia. Patients were placed prone, preliminary scan with TruFISP sequence was obtained on a 1.5T Espree (Siemens, Malvern, PA) scanner, and safe transgluteal route to area of interest was found. Overlying skin was prepped and draped and numbed with 1% Lidocaine. MR-safe 16-guage guide needle (Invivo, Gainesville, FL) was directed to the target lesion with intermittent scanning. MR-safe 18-gauge core biopsy needle (Invivo, Gainesville, FL) was then used coaxially to obtain core material (at least 3 samples). Results All biopsies were technically successful. 3 biopsies (30%) returned prostate cancer. 2 patients had upstaging of previously biopsy proven prostate cancer. 1 patient had multiple prior negative biopsies and was diagnosed with Gleason 7 disease. 3 biopsies (30%) showed prostatitis, highlighting the difficulties of PSA screening and imaging for prostate cancer. Conclusion Though TRUS prostate biopsy is the standard for diagnosing prostate cancer, there are limitations to this approach including low sensitivity, unreliable information about the Gleason score, and undersampling of certain parts of the prostate. Several studies have been done on MR guidance for prostate biopsy but most use a transrectal approach, which has associated problems such as infection and limitations in accessing certain areas of the prostate that can be avoided with a transgluteal approach. This study shows that TGMR prostate biopsy is feasible and can improve detection as well as staging of prostate cancer.