Lance A Mynderse | Mayo Clinic (original) (raw)

Papers by Lance A Mynderse

Cancer, 2007

BACKGROUND. A prospective, double-blind, 3-arm, parallel group, randomized clinical trial was per... more BACKGROUND. A prospective, double-blind, 3-arm, parallel group, randomized clinical trial was performed to compare 3 anesthetic techniques for preventing pain during prostate biopsy. METHODS. A total of 243 men undergoing a 12-core prostate biopsy were randomized to 1 of 3 anesthetic methods: 1) seminal vesical-prostatic base blockade, 2) intraprostatic blockade, and 3) apical-rectal blockade. Pain was estimated with the 10-point visual analog scale. Multivariate logistic regression evaluated factors predictive of pain. The Kruskal-Wallis test analyzed overall group comparisons and the Steel-Dwass test assessed between-group comparisons in pain scores. Proportional odds ordinal logistic regression quantified the ability of covariates and treatment arms to predict biopsy pain. These values are presented as odds ratios with confidence intervals (OR, 95% CI). RESULTS. From November 2005 to June 2006, 81 men were randomized to 3 study arms. Lidocaine administration was the most painful element of the procedure, while probe insertion was the least. Apical biopsies were routinely more painful than mid-gland biopsies, which were more painful than base biopsies. The apical-rectal blockade was the most painful to administer, but has lasting effects and led to better pain control than the prostatic base-seminal vesicle blockade. Similarly, the intraprostatic blockade was more effective than the prostatic base-seminal vesicle blockade. Besides pain reported at the time of anesthetic injection, no difference was identified between the intraprostatic and apical-rectal blockades. CONCLUSIONS. Mid and apical biopsies of the prostate are more painful than base biopsies. The seminal vesicle-prostatic base blockade is less effective than intraprostatic and apical-rectal blockade at controlling pain. Cancer 2007;

European Urology Supplements, Mar 1, 2007

Introduction & Objectives: Intraoperative radiotherapy (IORT) is a new radiotherapeutic technique... more Introduction & Objectives: Intraoperative radiotherapy (IORT) is a new radiotherapeutic technique that allow to give high doses of radiation during surgical treatment. It is currently used for different tumors like breast and rectum cancer. The aim of this study is to verify both the feasibility and the complications of IORT associated with radical prostatectomy for locally advanced prostate cancer. Material & Methods: Inclusion criteria were: patient's age < 75 years, no inflammatory bowel disease, clinical stage cT3-T4, cN0-1, M0, probability of extracapsular disease > 25% (Kattan's nomograms). The patients selected for the study, with prior written informed consent, were studied with CT scan to obtain pre-planning data. IORT uses a linear accelerator dedicated (Mobetron, Intraop, California, USA), installed in the operating room. After placing intra-rectal probe dosimeters, prostate is exposed, with the dissection of endopelvic fascia and puboprostatic ligaments. The distance between prostate and rectum is measured with intraoperative ultrasound. Therefore a collimator with a diameter of 5.0-6.0 cm and with an angle of "bevel" of 15-30° is introduced in the surgical field; it supplies a dose of 10-12 Gy with electrons from 9-12 Mev. The dose has been prescribed to the isodose of 90%. The volume treated includes the prostate, the seminal vessels and the periprostatic area. Than radical prostatectomy was done with an extended lymphadenectomy in all case. Results: From September 2005 we submitted to IORT 9 patients with cT2-cT3-cT4 prostate cancer. Mean patients age was 67 years. Mean PSA was 115.4 ng/ml (range 7-378); Gleason Score ranged from 7 to 10 in 8 patients and was 4 in one case. We observed no intra or perioperative complications. Mean IORT time was 30 minutes; the highest doses absorbed from rectum were from 0.1 to 2 Gy. Mean hospital stay was 8.5 day (range 5-18); one patient had prolonged post-operative dynamic ileum, two patients had bladder-neck stricture and one patient developed a lymphocele. Conclusions: The IORT, represents a new methodology feasible in acceptable surgical time and with minimal toxicity for rectum. A wider number of cases will be necessary to confirm these results.

The Journal of Urology, Apr 1, 2017

CONCLUSIONS: RP and RTAEADT provide comparable CSM outcomes for all localized risk group patients... more CONCLUSIONS: RP and RTAEADT provide comparable CSM outcomes for all localized risk group patients with PCa. The risk of OCM should be cautiously considered when making treatment decisions for old aged high risk patients with significant comorbidities.

European Urology, Jun 1, 2018

BACKGROUND The Stephenson nomogram is widely used to estimate the success of salvage radiotherapy... more BACKGROUND The Stephenson nomogram is widely used to estimate the success of salvage radiotherapy (sXRT) for prostate cancer (PCa) recurrence after radical prostatectomy (RP). OBJECTIVE To determine whether multiparametric pelvic magnetic resonance imaging (mpMRI) performed for biochemical recurrence after RP improves prognostication of sXRT relative to the Stephenson nomogram. DESIGN, SETTING, AND PARTICIPANTS Men undergoing RP at our institution from 2003 to 2012 who had biochemical recurrence evaluated by mpMRI within 12 mo of sXRT were retrospectively reviewed. Exclusion criteria included PCa treatment prior to RP, adjuvant XRT after RP, salvage cryotherapy before sXRT, and hormone refractory disease prior to sXRT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable Cox regression analyses (adjusting for Stephenson nomogram covariates) associated mpMRI findings with prostate-specific antigen (PSA) recurrence and metastasis after sXRT. The mpMR images were compared in a binary fashion: no lesion versus vesicourethral/seminal vesical bed/prostate fossa lesions. RESULTS AND LIMITATIONS Among 473 sXRT patients, 57%(204) had lesions on mpMRI: 26%(124) vesicourethral, 28%(135) seminal vesical bed/prostatic fossa, 7%(34) nodal, and 1%(3) bone. Median PSA at mpMRI with lesions was 0.46 versus 0.40ng/ml without lesions. After excluding nodal/bone lesions, 29% of men developed PSA recurrence and 14% metastasis (median follow-up 45 mo after sXRT). For patients with a pre-sXRT PSA of ≤0.5ng/ml, negative mpMRI was associated with increased PSA recurrence (39% vs 12%, p<0.01) and metastasis (16% vs 2%, p<0.01) at 4 yr after sXRT. For patients with a PSA of ≤0.5ng/ml, the addition of mpMRI to the propensity score (created using variables from the original Stephenson nomogram) improved the c-statistic from 0.71 to 0.77 for PSA recurrence (hazard ratio [HR] 3.60, p<0.01) and from 0.66 to 0.77 for metastasis (HR 6.68, p<0.01). Limitations include evolutions in MRI technique and lack of a cohort of men undergoing mpMRI electing against sXRT. CONCLUSIONS Pre-sXRT mpMRI improves clinicopathologic variables to estimate sXRT success, particularly in the early sXRT setting. PATIENT SUMMARY Men who have biochemically recurrent prostate cancer after radical prostatectomy often receive salvage radiotherapy. In our study, multiparametric pelvic magnetic resonance imaging prior to salvage radiotherapy was a significant predictor of prostate-specific antigen failure and metastasis after radiotherapy.

The Journal of Urology, Apr 1, 2014

Journal of Vascular and Interventional Radiology, Mar 1, 2016

Possibly interested 14.29% 7.14% Interested 42.86% 21.43% Very interested 14.29% 50% Definitely p... more Possibly interested 14.29% 7.14% Interested 42.86% 21.43% Very interested 14.29% 50% Definitely planning on going into IR 21.43% 21.43%

Abdominal Imaging, Feb 24, 2016

Prostate cancer is the most commonly diagnosed noncutaneous cancer and second-leading cause of de... more Prostate cancer is the most commonly diagnosed noncutaneous cancer and second-leading cause of death in men. Many patients with clinically organ confined prostate cancer undergo definitive treatment of the whole gland including radical prostatectomy, radiation therapy and cryosurgery. Active surveillance is a growing alternative option for patients with documented low volume, low grade prostate cancer. With recent advances in software and hardware of MRI, multiparametric MRI of the prostate has been shown to improve the accuracy in detecting and characterizing clinically significant prostate cancer. Targeted biopsy is increasingly utilized to improve the yield of MR detected, clinically significant prostate cancer and to decrease in detection of indolent prostate cancer. MR guided targeted biopsy techniques include cognitive MR fusion TRUS biopsy, in-bore transrectal targeted biopsy using robotic transrectal device, and in-bore direct MR guided transperineal biopsy with a software based transperineal grid template. In addition, advances in MR compatible thermal ablation technology allow accurate focal or regional delivery of optimal thermal energy to the biopsy proved, MRI detected tumor, utilizing cryoablation, laser ablation, high intensity focused ultrasound ablation under MR guidance and real time or near simultaneous monitoring of the ablation zone. Herein we present a contemporary review of MR guided targeted biopsy techniques of MR detected lesions as well as MR guided focal or regional thermal ablative therapies for localized naïve and recurrent cancerous foci of the prostate.

Seminars in Interventional Radiology, Aug 30, 2016

Objectives: Upon completion of this article, the reader will be able to identify the utility of M... more Objectives: Upon completion of this article, the reader will be able to identify the utility of MRI-guided biopsy of the prostate gland, the current commercially available units, and the advantages and drawbacks of each system. Accreditation: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Tufts University School of Medicine (TUSM) and Thieme Medical Publishers, New York. TUSM is accredited by the ACCME to provide continuing medical education for physicians. Credit: Tufts University School of Medicine designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The American Cancer Society (ACS) estimated that in 2016, there will be 180,890 newly diagnosed cases of prostate cancer with an estimated 26,120 deaths. The risk of prostate cancer is 70% higher in blacks than in non-Hispanic white males. Prostate cancer is the most commonly diagnosed noncutaneous cancer and second-leading cause of cancer death in men. 1 Unfortunately, it is unknown at which time an aggressive prostate cancer should be detected to attain the highest chance of cure. However, it seems intuitive that very early detection may play a role in preventing the development of metastatic disease. 2 In view of the significant disparity on Keywords ► needle biopsy ► MRI ► MRI targeted biopsy ► prostate cancer ► interventional radiology

Cryobiology, Aug 1, 2014

Introduction of urethral warmers to aid cryosurgery in the prostate has significantly reduced the... more Introduction of urethral warmers to aid cryosurgery in the prostate has significantly reduced the incidence of urethral sloughing; however, the incidence rate still remains as high as 15%. Furthermore, urethral warmers have been associated with an increase of cancer recurrence rates. Here, we report results from our phantom-based investigation to determine the impact of a urethral warmer on temperature distributions around cryoneedles during cryosurgery. Cryoablation treatments were simulated in a tissue mimicking phantom containing a urethral warming catheter. Four different configurations of cryoneedles relative to urethral warming catheter were investigated. For each configuration, the freeze-thaw cycles were repeated with and without the urethral warming system activated. Temperature histories were recorded at various prearranged positions relative to the cryoneedles and urethral warming catheter. In all configurations, the urethral warming system was effective at maintaining sub-lethal temperatures at the simulated surface of the urethra. The warmer action, however, was additionally demonstrated to potentially negatively impact treatment lethality in the target zone by elevating minimal temperatures to sub-lethal levels. In all needle configurations, rates of freezing and thawing were not significantly affected by the use of the urethral warmer. The results indicate that the urethral warming system can protect urethral tissue during cryoablation therapy with cryoneedles placed as close as 5 mm to the surface of the urethra. Using a urethral warming system and placing multiple cryoneedles within 1 cm of each other delivers lethal cooling at least 5 mm from the urethral surface while sparing urethral tissue.

Clinical Radiology, Aug 1, 2017

In 2016, it is estimated 180,890 men are newly diagnosed with prostate cancer and 3,306,760 men l... more In 2016, it is estimated 180,890 men are newly diagnosed with prostate cancer and 3,306,760 men live with prostate cancer in the United States. The introduction of multiparametric (mp) magnetic resonance imaging (MRI) of the prostate, standardised interpretation guidelines such as Prostate Imaging Reporting and Data System (PI-RADS version 2), and MRI-based targeted biopsy has improved detection of clinically significant prostate cancer. Accurate risk stratification (Gleason grade/score and tumour stage) using imaging and image-guided targeted biopsy has become critical for the management of patients with prostate cancer. Recent advances in MRI-guided minimally invasive ablative treatment (MIAT) utilising cryoablation, laser ablation, high-intensity focused ultrasound ablation, have allowed accurate focal or regional delivery of optimal thermal energy to the biopsy proven, MRI-detected tumour, under real-time or near simultaneous MRI monitoring of the ablation zone. A contemporary review on prostate mpMRI, MRI-based targeted biopsy, and MRI-guided ablation techniques is presented.

Journal of Vascular and Interventional Radiology, Jul 1, 2011

Biochemical recurrence of prostate cancer after definitive therapy with radical prostatectomy occ... more Biochemical recurrence of prostate cancer after definitive therapy with radical prostatectomy occurs in 25%Ϫ30% of cases. The first known case of magnetic resonance (MR) imaging-guided ablation using laser interstitial thermal therapy (LITT) for locally recurrent prostate cancer after radical prostatectomy is presented. Using 3.0T MR guidance, two laser applicators were placed via a transperineal approach. Laser ablation was performed using MR thermometry to determine the ablation endpoint and lesion coverage. Dynamic contrast-enhanced MR imaging after the procedure showed no definitive abnormal enhancement. The patient had no change in continence or potency after the procedure. ABBREVIATIONS DCE ϭ dynamic contrast enhancement, LITT ϭ laser interstitial thermal therapy (LITT), PRF ϭ proton resonance frequency, PSA ϭ prostate-specific antigen From the Departments of Radiology (D.A

Mayo Clinic Proceedings, Nov 1, 2021

Journal of Vascular and Interventional Radiology, Feb 1, 2010

toneal ϭ30, intraperitoneal ϭ51, superficial ϭ47 and bone ϭ29) in 97 patients. Protection of adja... more toneal ϭ30, intraperitoneal ϭ51, superficial ϭ47 and bone ϭ29) in 97 patients. Protection of adjacent crucial tissues (e.g. skin, bowel) from cytotoxic temperatures (e.g., Ͻ-20C) was achieved by thermocouple monitoring, saline injection and/or direct skin warming. Complications were graded according to Common Toxicity Criteria for Adverse Events Version 3.0 (CTCAE). Patients were followed by CT or MRI and local recurrence was defined as any asymmetric nodular enhancement of the cryozone and/or ablation site enlargement. Resorption was calculated from ablation zone measurements at 1, 3, 6, 12, 18, and 24ϩ months. Results: The cryotherapy zone was well defined by CT as a hypodense ice ball with an average ablation diameter of 5.4 cm, while average tumor diameter was 3.5 cm. Major complications (CTCAE Grade Ͼ3) occurred in 7 patients (4%). After an average follow-up of 14 months (range: 0.25-79), a total of 23 recurrences (15%) were noted, of which 8 (35%) abutted and 15 (65%) were satellite lesions (5-10mm beyond ablation zone). A 2:1 ratio of distant to local recurrence, suggested good local cancer control for difficult patients. By 24 months there was a total volume reduction of 77.2%. Conclusion: Percutaneous soft tissue cryotherapy is a well tolerated treatment alternative, especially for patients with anesthesia risks, painful lesions, or those seeking local control during chemotherapy. Tumor size and/or location do not preclude thorough treatment or pose greater risk with appropriate precautions.

The Journal of Urology, Apr 1, 2010

The Journal of Urology, Apr 1, 2014

INTRODUCTION AND OBJECTIVES: Multiparametric 3T MRI (MP-MRI) with the use of an endorectal coil (... more INTRODUCTION AND OBJECTIVES: Multiparametric 3T MRI (MP-MRI) with the use of an endorectal coil (ERC) provides improved signal to noise ratio for evaluation of prostatic lesions suspicious for prostate cancer. Herein, we aim to determine the degree of lesion identification lost by eliminating the use of an ERC based upon measures of obesity. METHODS: Prospectively collected data on 20 patients on an active surveillance protocol at the National Cancer Institute who have undergone non-ERC MP-MRI in 2013 following a prior ERC MP-MRI were analyzed. MP-MRI prostatic lesions suspicious for prostate cancer were identified and recorded on both ERC and non-ERC studies for each patient. Patient demographics including age, PSA, BMI, abdominal girth, waist circumference, and the drop distance from the anterior abdominal wall to the anterior aspect of the prostate were recorded. Quantitative measures of obesity were measured on T2-weighted MRI sequences. These parameters were analyzed using univariate and multivariable linear regression models individually with age and PSA to assess for significance in the decrease in number of lesions identified on followup studies without ERC use. RESULTS: The average number of lesions identified on ERC MP-MRI and followup non-ERC MP-MRI was 1.4AE0.9 and 0.5AE0.7, respectively. On univariate analysis, age and PSA were not significantly associated with a decrease in the number of lesions identified when the ERC was not used on followup MP-MRI. Of the quantitative parameters of obesity, on univariate analysis, greater BMI (p¼0.01) and abdominal girth (p¼0.0097) were significantly associated with a larger differential in the number of lesions identified. On multivariable linear regression models incorporating each of the measures of obesity with age and PSA, BMI (p¼0.026) and abdominal girth (p¼0.019) remained significant independent predictors of the difference in numbers of lesions identified between ERC and non-ERC studies. CONCLUSIONS: Typically more intraprostatic lesions are identified by MP-MRI performed with ERC due to the optimized signal to noise ratio. This difference is more dramatic in obese patients where the distance between body and surface coils and the prostate gland are increased. BMI and abdominal girth are predictors of significantly lower lesion identification when ERC is eliminated from the MP-MRI study. Since obesity has a negative impact on the detection of prostate cancer with non-ERC MRI, ERC use may be most important in this patient population.

International Journal of Radiation Oncology Biology Physics, Oct 1, 2005

implant. CT scans were obtained within 4 hours of the implant for postimplant dosimetry. Seed pla... more implant. CT scans were obtained within 4 hours of the implant for postimplant dosimetry. Seed placement was determined using Variseed (version 7.0, Charlottesville, NC), with a redundancy check to prevent seed duplication. The prostate and rectum were contoured on the CT images by one investigator. Three dosimetric parameters were then calculated: 1) D90 (percent of the prescription dose covering 90% of the prostate volume); 2) V100 (percent of the total prostate volume getting 100% of the prescription dose); and 3) R100 (volume in cm 3 of the rectum receiving 100% of the prescription dose). Patients were then followed with serial PSA measurements taken every 6 to 12 months. Biochemical failure was defined as a serum PSA Ͼ0.5 ng/mL at the last follow-up. Patients were censored at the last follow-up if their serum PSA was still decreasing. Patients whose serum PSA nadired at a value Ͼ0.5 ng/mL were scored as failures at the time of their nadirs. The ASTRO criteria for biochemical failure (defined as three consecutive rises) was not used, because most of the patients had their PSA measurements taken on an annual basis. Results: The median follow-up for all patients was 3.0 years (range 0.3 to 5.3 years). The median follow-up for non-failing patients was 3.1 years (range 1.1 to 5.3 years). Of the 182 patients analyzed in this study, 21 patients had biochemical failures (for a 3-year biochemical freedom from failure rate [FFF] of 89%). The D90 and V100 values were significantly associated with a greater likelihood of biochemical control. The 3-year biochemical FFF rate was 92% for patients with a D90 Ն90% versus 76% for patients with a D90 Ͻ90% (pϭ0.01). The 3-year biochemical FFF rate was 96% for patients with a V100 Ն90% versus 83% for patients with a V100 Ͻ90% (pϭ0.02). In comparison, there was no significant association between the R100 value and the likelihood of biochemical control. The 3-year biochemical FFF rate was 88% for patients with a R100 Ն1.0 cm 3 versus 90% for patients with R100 Ͻ1.0 cm 3 (pϭ0.68).

European Urology, May 1, 2008

Objective: Prostate biopsy remains the gold standard for detection of prostate cancer (PCa). This... more Objective: Prostate biopsy remains the gold standard for detection of prostate cancer (PCa). This study was performed to determine whether saturation biopsy (24 cores) detects more prostate cancer than a standard 12-18 core office biopsy technique. Methods: We conducted a nonrandomized cohort study of a consecutive series of prostate biopsies. The primary outcome assessed by both univariate and multivariate analysis was the detection of PCa, whereas the secondary outcomes of HGPIN (high-grade prostatic intraepithelial neoplasia) and ASAP (atypical small acinar proliferation) were also analyzed. Results: From September 2005 to June 2006, a total of 469 patients undergoing prostate biopsy were included in this study. A standard office prostate biopsy was performed in 301 men, whereas 168 underwent a saturation biopsy. Age, body mass index (BMI), prostate volume, and family history of PCa were similar. However, patients in the saturation biopsy cohort were more likely to have had prior biopsies, higher prebiopsy PSA, longer PSA doubling times, and to carry more frequent diagnoses of HGPIN or ASAP (all p < 0.05). After adjusting for covariates, saturation biopsy did not detect more abnormal pathology than standard office prostate biopsy, including PCa (OR, 1.2; p = 0.339), HGPIN (OR, 1.4; p = 0.368), or ASAP (OR, 2.2; p = 0.201). Conclusions: Saturation biopsy does not appear to detect more abnormal prostate pathology than standard office biopsy of the prostate. This procedure may be associated with increased cost and patient morbidity.

PLOS ONE

Purpose To compare the inter-observer variability of apparent diffusion coefficient (ADC) values ... more Purpose To compare the inter-observer variability of apparent diffusion coefficient (ADC) values of prostate lesions measured by 2D-region of interest (ROI) with and without specific measurement instruction. Methods Forty lesions in 40 patients who underwent prostate MR followed by targeted prostate biopsy were evaluated. A multi-reader study (10 readers) was performed to assess the agreement of ADC values between 2D-ROI without specific instruction and 2D-ROI with specific instruction to place a 9-pixel size 2D-ROI covering the lowest ADC area. The computer script generated multiple overlapping 9-pixel 2D-ROIs within a 3D-ROI encompassing the entire lesion placed by a single reader. The lowest mean ADC values from each 2D-small-ROI were used as reference values. Inter-observer agreement was assessed using the Bland-Altman plot. Intraclass correlation coefficient (ICC) was assessed between ADC values measured by 10 readers and the computer-calculated reference values. Results Ten le...

Cancer, 2007

BACKGROUND. A prospective, double-blind, 3-arm, parallel group, randomized clinical trial was per... more BACKGROUND. A prospective, double-blind, 3-arm, parallel group, randomized clinical trial was performed to compare 3 anesthetic techniques for preventing pain during prostate biopsy. METHODS. A total of 243 men undergoing a 12-core prostate biopsy were randomized to 1 of 3 anesthetic methods: 1) seminal vesical-prostatic base blockade, 2) intraprostatic blockade, and 3) apical-rectal blockade. Pain was estimated with the 10-point visual analog scale. Multivariate logistic regression evaluated factors predictive of pain. The Kruskal-Wallis test analyzed overall group comparisons and the Steel-Dwass test assessed between-group comparisons in pain scores. Proportional odds ordinal logistic regression quantified the ability of covariates and treatment arms to predict biopsy pain. These values are presented as odds ratios with confidence intervals (OR, 95% CI). RESULTS. From November 2005 to June 2006, 81 men were randomized to 3 study arms. Lidocaine administration was the most painful element of the procedure, while probe insertion was the least. Apical biopsies were routinely more painful than mid-gland biopsies, which were more painful than base biopsies. The apical-rectal blockade was the most painful to administer, but has lasting effects and led to better pain control than the prostatic base-seminal vesicle blockade. Similarly, the intraprostatic blockade was more effective than the prostatic base-seminal vesicle blockade. Besides pain reported at the time of anesthetic injection, no difference was identified between the intraprostatic and apical-rectal blockades. CONCLUSIONS. Mid and apical biopsies of the prostate are more painful than base biopsies. The seminal vesicle-prostatic base blockade is less effective than intraprostatic and apical-rectal blockade at controlling pain. Cancer 2007;

European Urology Supplements, Mar 1, 2007

Introduction & Objectives: Intraoperative radiotherapy (IORT) is a new radiotherapeutic technique... more Introduction & Objectives: Intraoperative radiotherapy (IORT) is a new radiotherapeutic technique that allow to give high doses of radiation during surgical treatment. It is currently used for different tumors like breast and rectum cancer. The aim of this study is to verify both the feasibility and the complications of IORT associated with radical prostatectomy for locally advanced prostate cancer. Material & Methods: Inclusion criteria were: patient's age < 75 years, no inflammatory bowel disease, clinical stage cT3-T4, cN0-1, M0, probability of extracapsular disease > 25% (Kattan's nomograms). The patients selected for the study, with prior written informed consent, were studied with CT scan to obtain pre-planning data. IORT uses a linear accelerator dedicated (Mobetron, Intraop, California, USA), installed in the operating room. After placing intra-rectal probe dosimeters, prostate is exposed, with the dissection of endopelvic fascia and puboprostatic ligaments. The distance between prostate and rectum is measured with intraoperative ultrasound. Therefore a collimator with a diameter of 5.0-6.0 cm and with an angle of "bevel" of 15-30° is introduced in the surgical field; it supplies a dose of 10-12 Gy with electrons from 9-12 Mev. The dose has been prescribed to the isodose of 90%. The volume treated includes the prostate, the seminal vessels and the periprostatic area. Than radical prostatectomy was done with an extended lymphadenectomy in all case. Results: From September 2005 we submitted to IORT 9 patients with cT2-cT3-cT4 prostate cancer. Mean patients age was 67 years. Mean PSA was 115.4 ng/ml (range 7-378); Gleason Score ranged from 7 to 10 in 8 patients and was 4 in one case. We observed no intra or perioperative complications. Mean IORT time was 30 minutes; the highest doses absorbed from rectum were from 0.1 to 2 Gy. Mean hospital stay was 8.5 day (range 5-18); one patient had prolonged post-operative dynamic ileum, two patients had bladder-neck stricture and one patient developed a lymphocele. Conclusions: The IORT, represents a new methodology feasible in acceptable surgical time and with minimal toxicity for rectum. A wider number of cases will be necessary to confirm these results.

The Journal of Urology, Apr 1, 2017

CONCLUSIONS: RP and RTAEADT provide comparable CSM outcomes for all localized risk group patients... more CONCLUSIONS: RP and RTAEADT provide comparable CSM outcomes for all localized risk group patients with PCa. The risk of OCM should be cautiously considered when making treatment decisions for old aged high risk patients with significant comorbidities.

European Urology, Jun 1, 2018

BACKGROUND The Stephenson nomogram is widely used to estimate the success of salvage radiotherapy... more BACKGROUND The Stephenson nomogram is widely used to estimate the success of salvage radiotherapy (sXRT) for prostate cancer (PCa) recurrence after radical prostatectomy (RP). OBJECTIVE To determine whether multiparametric pelvic magnetic resonance imaging (mpMRI) performed for biochemical recurrence after RP improves prognostication of sXRT relative to the Stephenson nomogram. DESIGN, SETTING, AND PARTICIPANTS Men undergoing RP at our institution from 2003 to 2012 who had biochemical recurrence evaluated by mpMRI within 12 mo of sXRT were retrospectively reviewed. Exclusion criteria included PCa treatment prior to RP, adjuvant XRT after RP, salvage cryotherapy before sXRT, and hormone refractory disease prior to sXRT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable Cox regression analyses (adjusting for Stephenson nomogram covariates) associated mpMRI findings with prostate-specific antigen (PSA) recurrence and metastasis after sXRT. The mpMR images were compared in a binary fashion: no lesion versus vesicourethral/seminal vesical bed/prostate fossa lesions. RESULTS AND LIMITATIONS Among 473 sXRT patients, 57%(204) had lesions on mpMRI: 26%(124) vesicourethral, 28%(135) seminal vesical bed/prostatic fossa, 7%(34) nodal, and 1%(3) bone. Median PSA at mpMRI with lesions was 0.46 versus 0.40ng/ml without lesions. After excluding nodal/bone lesions, 29% of men developed PSA recurrence and 14% metastasis (median follow-up 45 mo after sXRT). For patients with a pre-sXRT PSA of ≤0.5ng/ml, negative mpMRI was associated with increased PSA recurrence (39% vs 12%, p<0.01) and metastasis (16% vs 2%, p<0.01) at 4 yr after sXRT. For patients with a PSA of ≤0.5ng/ml, the addition of mpMRI to the propensity score (created using variables from the original Stephenson nomogram) improved the c-statistic from 0.71 to 0.77 for PSA recurrence (hazard ratio [HR] 3.60, p<0.01) and from 0.66 to 0.77 for metastasis (HR 6.68, p<0.01). Limitations include evolutions in MRI technique and lack of a cohort of men undergoing mpMRI electing against sXRT. CONCLUSIONS Pre-sXRT mpMRI improves clinicopathologic variables to estimate sXRT success, particularly in the early sXRT setting. PATIENT SUMMARY Men who have biochemically recurrent prostate cancer after radical prostatectomy often receive salvage radiotherapy. In our study, multiparametric pelvic magnetic resonance imaging prior to salvage radiotherapy was a significant predictor of prostate-specific antigen failure and metastasis after radiotherapy.

The Journal of Urology, Apr 1, 2014

Journal of Vascular and Interventional Radiology, Mar 1, 2016

Possibly interested 14.29% 7.14% Interested 42.86% 21.43% Very interested 14.29% 50% Definitely p... more Possibly interested 14.29% 7.14% Interested 42.86% 21.43% Very interested 14.29% 50% Definitely planning on going into IR 21.43% 21.43%

Abdominal Imaging, Feb 24, 2016

Prostate cancer is the most commonly diagnosed noncutaneous cancer and second-leading cause of de... more Prostate cancer is the most commonly diagnosed noncutaneous cancer and second-leading cause of death in men. Many patients with clinically organ confined prostate cancer undergo definitive treatment of the whole gland including radical prostatectomy, radiation therapy and cryosurgery. Active surveillance is a growing alternative option for patients with documented low volume, low grade prostate cancer. With recent advances in software and hardware of MRI, multiparametric MRI of the prostate has been shown to improve the accuracy in detecting and characterizing clinically significant prostate cancer. Targeted biopsy is increasingly utilized to improve the yield of MR detected, clinically significant prostate cancer and to decrease in detection of indolent prostate cancer. MR guided targeted biopsy techniques include cognitive MR fusion TRUS biopsy, in-bore transrectal targeted biopsy using robotic transrectal device, and in-bore direct MR guided transperineal biopsy with a software based transperineal grid template. In addition, advances in MR compatible thermal ablation technology allow accurate focal or regional delivery of optimal thermal energy to the biopsy proved, MRI detected tumor, utilizing cryoablation, laser ablation, high intensity focused ultrasound ablation under MR guidance and real time or near simultaneous monitoring of the ablation zone. Herein we present a contemporary review of MR guided targeted biopsy techniques of MR detected lesions as well as MR guided focal or regional thermal ablative therapies for localized naïve and recurrent cancerous foci of the prostate.

Seminars in Interventional Radiology, Aug 30, 2016

Objectives: Upon completion of this article, the reader will be able to identify the utility of M... more Objectives: Upon completion of this article, the reader will be able to identify the utility of MRI-guided biopsy of the prostate gland, the current commercially available units, and the advantages and drawbacks of each system. Accreditation: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Tufts University School of Medicine (TUSM) and Thieme Medical Publishers, New York. TUSM is accredited by the ACCME to provide continuing medical education for physicians. Credit: Tufts University School of Medicine designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The American Cancer Society (ACS) estimated that in 2016, there will be 180,890 newly diagnosed cases of prostate cancer with an estimated 26,120 deaths. The risk of prostate cancer is 70% higher in blacks than in non-Hispanic white males. Prostate cancer is the most commonly diagnosed noncutaneous cancer and second-leading cause of cancer death in men. 1 Unfortunately, it is unknown at which time an aggressive prostate cancer should be detected to attain the highest chance of cure. However, it seems intuitive that very early detection may play a role in preventing the development of metastatic disease. 2 In view of the significant disparity on Keywords ► needle biopsy ► MRI ► MRI targeted biopsy ► prostate cancer ► interventional radiology

Cryobiology, Aug 1, 2014

Introduction of urethral warmers to aid cryosurgery in the prostate has significantly reduced the... more Introduction of urethral warmers to aid cryosurgery in the prostate has significantly reduced the incidence of urethral sloughing; however, the incidence rate still remains as high as 15%. Furthermore, urethral warmers have been associated with an increase of cancer recurrence rates. Here, we report results from our phantom-based investigation to determine the impact of a urethral warmer on temperature distributions around cryoneedles during cryosurgery. Cryoablation treatments were simulated in a tissue mimicking phantom containing a urethral warming catheter. Four different configurations of cryoneedles relative to urethral warming catheter were investigated. For each configuration, the freeze-thaw cycles were repeated with and without the urethral warming system activated. Temperature histories were recorded at various prearranged positions relative to the cryoneedles and urethral warming catheter. In all configurations, the urethral warming system was effective at maintaining sub-lethal temperatures at the simulated surface of the urethra. The warmer action, however, was additionally demonstrated to potentially negatively impact treatment lethality in the target zone by elevating minimal temperatures to sub-lethal levels. In all needle configurations, rates of freezing and thawing were not significantly affected by the use of the urethral warmer. The results indicate that the urethral warming system can protect urethral tissue during cryoablation therapy with cryoneedles placed as close as 5 mm to the surface of the urethra. Using a urethral warming system and placing multiple cryoneedles within 1 cm of each other delivers lethal cooling at least 5 mm from the urethral surface while sparing urethral tissue.

Clinical Radiology, Aug 1, 2017

In 2016, it is estimated 180,890 men are newly diagnosed with prostate cancer and 3,306,760 men l... more In 2016, it is estimated 180,890 men are newly diagnosed with prostate cancer and 3,306,760 men live with prostate cancer in the United States. The introduction of multiparametric (mp) magnetic resonance imaging (MRI) of the prostate, standardised interpretation guidelines such as Prostate Imaging Reporting and Data System (PI-RADS version 2), and MRI-based targeted biopsy has improved detection of clinically significant prostate cancer. Accurate risk stratification (Gleason grade/score and tumour stage) using imaging and image-guided targeted biopsy has become critical for the management of patients with prostate cancer. Recent advances in MRI-guided minimally invasive ablative treatment (MIAT) utilising cryoablation, laser ablation, high-intensity focused ultrasound ablation, have allowed accurate focal or regional delivery of optimal thermal energy to the biopsy proven, MRI-detected tumour, under real-time or near simultaneous MRI monitoring of the ablation zone. A contemporary review on prostate mpMRI, MRI-based targeted biopsy, and MRI-guided ablation techniques is presented.

Journal of Vascular and Interventional Radiology, Jul 1, 2011

Biochemical recurrence of prostate cancer after definitive therapy with radical prostatectomy occ... more Biochemical recurrence of prostate cancer after definitive therapy with radical prostatectomy occurs in 25%Ϫ30% of cases. The first known case of magnetic resonance (MR) imaging-guided ablation using laser interstitial thermal therapy (LITT) for locally recurrent prostate cancer after radical prostatectomy is presented. Using 3.0T MR guidance, two laser applicators were placed via a transperineal approach. Laser ablation was performed using MR thermometry to determine the ablation endpoint and lesion coverage. Dynamic contrast-enhanced MR imaging after the procedure showed no definitive abnormal enhancement. The patient had no change in continence or potency after the procedure. ABBREVIATIONS DCE ϭ dynamic contrast enhancement, LITT ϭ laser interstitial thermal therapy (LITT), PRF ϭ proton resonance frequency, PSA ϭ prostate-specific antigen From the Departments of Radiology (D.A

Mayo Clinic Proceedings, Nov 1, 2021

Journal of Vascular and Interventional Radiology, Feb 1, 2010

toneal ϭ30, intraperitoneal ϭ51, superficial ϭ47 and bone ϭ29) in 97 patients. Protection of adja... more toneal ϭ30, intraperitoneal ϭ51, superficial ϭ47 and bone ϭ29) in 97 patients. Protection of adjacent crucial tissues (e.g. skin, bowel) from cytotoxic temperatures (e.g., Ͻ-20C) was achieved by thermocouple monitoring, saline injection and/or direct skin warming. Complications were graded according to Common Toxicity Criteria for Adverse Events Version 3.0 (CTCAE). Patients were followed by CT or MRI and local recurrence was defined as any asymmetric nodular enhancement of the cryozone and/or ablation site enlargement. Resorption was calculated from ablation zone measurements at 1, 3, 6, 12, 18, and 24ϩ months. Results: The cryotherapy zone was well defined by CT as a hypodense ice ball with an average ablation diameter of 5.4 cm, while average tumor diameter was 3.5 cm. Major complications (CTCAE Grade Ͼ3) occurred in 7 patients (4%). After an average follow-up of 14 months (range: 0.25-79), a total of 23 recurrences (15%) were noted, of which 8 (35%) abutted and 15 (65%) were satellite lesions (5-10mm beyond ablation zone). A 2:1 ratio of distant to local recurrence, suggested good local cancer control for difficult patients. By 24 months there was a total volume reduction of 77.2%. Conclusion: Percutaneous soft tissue cryotherapy is a well tolerated treatment alternative, especially for patients with anesthesia risks, painful lesions, or those seeking local control during chemotherapy. Tumor size and/or location do not preclude thorough treatment or pose greater risk with appropriate precautions.

The Journal of Urology, Apr 1, 2010

The Journal of Urology, Apr 1, 2014

INTRODUCTION AND OBJECTIVES: Multiparametric 3T MRI (MP-MRI) with the use of an endorectal coil (... more INTRODUCTION AND OBJECTIVES: Multiparametric 3T MRI (MP-MRI) with the use of an endorectal coil (ERC) provides improved signal to noise ratio for evaluation of prostatic lesions suspicious for prostate cancer. Herein, we aim to determine the degree of lesion identification lost by eliminating the use of an ERC based upon measures of obesity. METHODS: Prospectively collected data on 20 patients on an active surveillance protocol at the National Cancer Institute who have undergone non-ERC MP-MRI in 2013 following a prior ERC MP-MRI were analyzed. MP-MRI prostatic lesions suspicious for prostate cancer were identified and recorded on both ERC and non-ERC studies for each patient. Patient demographics including age, PSA, BMI, abdominal girth, waist circumference, and the drop distance from the anterior abdominal wall to the anterior aspect of the prostate were recorded. Quantitative measures of obesity were measured on T2-weighted MRI sequences. These parameters were analyzed using univariate and multivariable linear regression models individually with age and PSA to assess for significance in the decrease in number of lesions identified on followup studies without ERC use. RESULTS: The average number of lesions identified on ERC MP-MRI and followup non-ERC MP-MRI was 1.4AE0.9 and 0.5AE0.7, respectively. On univariate analysis, age and PSA were not significantly associated with a decrease in the number of lesions identified when the ERC was not used on followup MP-MRI. Of the quantitative parameters of obesity, on univariate analysis, greater BMI (p¼0.01) and abdominal girth (p¼0.0097) were significantly associated with a larger differential in the number of lesions identified. On multivariable linear regression models incorporating each of the measures of obesity with age and PSA, BMI (p¼0.026) and abdominal girth (p¼0.019) remained significant independent predictors of the difference in numbers of lesions identified between ERC and non-ERC studies. CONCLUSIONS: Typically more intraprostatic lesions are identified by MP-MRI performed with ERC due to the optimized signal to noise ratio. This difference is more dramatic in obese patients where the distance between body and surface coils and the prostate gland are increased. BMI and abdominal girth are predictors of significantly lower lesion identification when ERC is eliminated from the MP-MRI study. Since obesity has a negative impact on the detection of prostate cancer with non-ERC MRI, ERC use may be most important in this patient population.

International Journal of Radiation Oncology Biology Physics, Oct 1, 2005

implant. CT scans were obtained within 4 hours of the implant for postimplant dosimetry. Seed pla... more implant. CT scans were obtained within 4 hours of the implant for postimplant dosimetry. Seed placement was determined using Variseed (version 7.0, Charlottesville, NC), with a redundancy check to prevent seed duplication. The prostate and rectum were contoured on the CT images by one investigator. Three dosimetric parameters were then calculated: 1) D90 (percent of the prescription dose covering 90% of the prostate volume); 2) V100 (percent of the total prostate volume getting 100% of the prescription dose); and 3) R100 (volume in cm 3 of the rectum receiving 100% of the prescription dose). Patients were then followed with serial PSA measurements taken every 6 to 12 months. Biochemical failure was defined as a serum PSA Ͼ0.5 ng/mL at the last follow-up. Patients were censored at the last follow-up if their serum PSA was still decreasing. Patients whose serum PSA nadired at a value Ͼ0.5 ng/mL were scored as failures at the time of their nadirs. The ASTRO criteria for biochemical failure (defined as three consecutive rises) was not used, because most of the patients had their PSA measurements taken on an annual basis. Results: The median follow-up for all patients was 3.0 years (range 0.3 to 5.3 years). The median follow-up for non-failing patients was 3.1 years (range 1.1 to 5.3 years). Of the 182 patients analyzed in this study, 21 patients had biochemical failures (for a 3-year biochemical freedom from failure rate [FFF] of 89%). The D90 and V100 values were significantly associated with a greater likelihood of biochemical control. The 3-year biochemical FFF rate was 92% for patients with a D90 Ն90% versus 76% for patients with a D90 Ͻ90% (pϭ0.01). The 3-year biochemical FFF rate was 96% for patients with a V100 Ն90% versus 83% for patients with a V100 Ͻ90% (pϭ0.02). In comparison, there was no significant association between the R100 value and the likelihood of biochemical control. The 3-year biochemical FFF rate was 88% for patients with a R100 Ն1.0 cm 3 versus 90% for patients with R100 Ͻ1.0 cm 3 (pϭ0.68).

European Urology, May 1, 2008

Objective: Prostate biopsy remains the gold standard for detection of prostate cancer (PCa). This... more Objective: Prostate biopsy remains the gold standard for detection of prostate cancer (PCa). This study was performed to determine whether saturation biopsy (24 cores) detects more prostate cancer than a standard 12-18 core office biopsy technique. Methods: We conducted a nonrandomized cohort study of a consecutive series of prostate biopsies. The primary outcome assessed by both univariate and multivariate analysis was the detection of PCa, whereas the secondary outcomes of HGPIN (high-grade prostatic intraepithelial neoplasia) and ASAP (atypical small acinar proliferation) were also analyzed. Results: From September 2005 to June 2006, a total of 469 patients undergoing prostate biopsy were included in this study. A standard office prostate biopsy was performed in 301 men, whereas 168 underwent a saturation biopsy. Age, body mass index (BMI), prostate volume, and family history of PCa were similar. However, patients in the saturation biopsy cohort were more likely to have had prior biopsies, higher prebiopsy PSA, longer PSA doubling times, and to carry more frequent diagnoses of HGPIN or ASAP (all p < 0.05). After adjusting for covariates, saturation biopsy did not detect more abnormal pathology than standard office prostate biopsy, including PCa (OR, 1.2; p = 0.339), HGPIN (OR, 1.4; p = 0.368), or ASAP (OR, 2.2; p = 0.201). Conclusions: Saturation biopsy does not appear to detect more abnormal prostate pathology than standard office biopsy of the prostate. This procedure may be associated with increased cost and patient morbidity.

PLOS ONE

Purpose To compare the inter-observer variability of apparent diffusion coefficient (ADC) values ... more Purpose To compare the inter-observer variability of apparent diffusion coefficient (ADC) values of prostate lesions measured by 2D-region of interest (ROI) with and without specific measurement instruction. Methods Forty lesions in 40 patients who underwent prostate MR followed by targeted prostate biopsy were evaluated. A multi-reader study (10 readers) was performed to assess the agreement of ADC values between 2D-ROI without specific instruction and 2D-ROI with specific instruction to place a 9-pixel size 2D-ROI covering the lowest ADC area. The computer script generated multiple overlapping 9-pixel 2D-ROIs within a 3D-ROI encompassing the entire lesion placed by a single reader. The lowest mean ADC values from each 2D-small-ROI were used as reference values. Inter-observer agreement was assessed using the Bland-Altman plot. Intraclass correlation coefficient (ICC) was assessed between ADC values measured by 10 readers and the computer-calculated reference values. Results Ten le...