Topic: Imaging

Risk-Adapted TURBT

Risk-Adapted TURBT

by | Feb 2023

In this 20-minute video, Seth P. Lerner, MD, Professor of Urology and Vice-chair for Faculty Affairs in the Scott Department of Urology, and Director of Urologic Oncology and the Multidisciplinary Bladder Cancer Program at Baylor University, discusses risk-adapted transurethral resection of bladder tumor (TURBT). He assesses TURBT’s role in staging and treatment and considers its use in bladder preservation.

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Bladder Sparing Tri-Modal Therapy Updates

Bladder Sparing Tri-Modal Therapy Updates

by | Feb 2023

In this 24-minute video, Daniel A. Hamstra, MD, PhD, Professor and Chair of Radiation Oncology at Baylor College of Medicine, discusses the viable but under-utilized therapy of trimodal bladder preservation. He specifically explores the role of surgery, chemotherapy, radiotherapy (RT), and check-point inhibitors in bladder sparing therapy.

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Non-Muscle Invasive Bladder Cancer: Guidelines-Based Approach

by | May 2022

Raj S. Pruthi, MD, MHA, FACS, Professor in the Department of Urology at the University of California, San Francisco, reviews the American Urological Association (AUA)-Society of Urologic Oncology (SUO) guidelines on diagnosing and treating non-muscle invasive bladder cancer (NMIBC). He begins with some statistics, relating that in 2017, there were approximately 79,000 new cases of bladder cancer, 16,800 deaths, and greater than 500,000 survivors. Dr. Pruthi observes that bladder cancer is a disease of older individuals, and he predicts that the population of bladder cancer patients will increase as the population ages. He then highlights key facts about NMIBC, explaining that most patients recur, some progress, and the ability to predict recurrence and progression is based on patient-specific disease characteristics. Dr. Pruthi introduces the 2016 AUA/SUO guidelines, noting that the panel featured a patient advocate. He goes over the guidelines point by point, starting with diagnosis. Dr. Pruthi underscores the importance of performing a complete visual transurethral resection of bladder tumor (TURBT) at initial diagnosis, explaining that incomplete TURBT is a contributing factor to early recurrences. He notes that risk calculators for NMIBC are limited by lack of applicability to current populations, and also that no study has evaluated the effectiveness of urinary biomarkers to decrease mortality or improve outcomes compared with standard diagnostic methods. When discussing guidelines around treatment, Dr. Pruthi emphasizes the importance of re-resecting T1 disease since understaging occurs in about 30% of cases and patients with residual T1 (after presumed complete resection) have up to an 80% chance of progression. He also discusses guidelines around BCG administration and BCG relapse. Dr. Pruthi then looks at cystectomy, arguing that waiting until progression to muscle invasion may prove fatal. He concludes by discussing guidelines around follow up.

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Panel Discussion – Focus on PSMA

Panel Discussion – Focus on PSMA

by | Dec 2021

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, leads a panel discussion focused on PSMA PET-CT’s expanding role in prostate cancer screening and diagnosis. The conversation begins with a look at how PSMA ligands are produced and distributed and what this means for access. Jérémie Calais, MD, MSc, Director of the Clinical Research Program of the Ahmanson Translational Theranostics Division of the Department of Molecular and Medical Pharmacology at UCLA, explains the differences between Gallium-68 PSMA-11 and 18F-DCFPyL, noting that the capacity of production and distribution is greater for the latter than the former. He argues, however, that the tracer used does not ultimately matter. E. David Crawford, MD, Professor of Urology at UCSD, observes that there have not actually been any comparative trials of gallium vs. PyL scans, and he suggests that there might be subtle differences in efficacy. Dr. Calais agrees that there is some disparity, but he does not think they are significant enough to affect staging or clinical management decisions. The discussion continues with a brief consideration of PSMA’s potential in theranostics and a look at whether PSMA scans can be trusted without confirmation from biopsy. Dr. Crawford notes that while biopsies are important and should be obtained when possible, as trust grows in the PSMA scans they may become less necessary. Dr. Calais and Dr. Koo then consider the potential for PSMA tests to be reimbursed, observing that they are not yet covered by Medicare but that there is a potential that they will be covered by insurance relatively soon. Dr. Crawford then asks whether the older CT and bone scans will be replaced by scans like PSMA, and the panelists conclude that they inevitably will but that costs will make this shift take some time.

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Current Status of PSMA Diagnostics

by | Aug 2021

Jeremie Calais, MD, MSc, Assistant Professor and Director of the Clinical Research Program in the Ahmanson Translational Theranostics Division of the Department of Molecular and Medical Pharmacology at UCLA, discusses PSMA diagnostics and compares imaging modalities to establish which modality is ideal for prostate cancer staging. He shares the FDA guidelines, stating that Ga 68 PSMA-11 is to be used for patients with prostate cancer (PCa) with suspected metastasis who are candidates for definitive therapy, and with suspected recurrence based on elevated serum prostate-specific antigen (PSA) level. Dr. Calais summarizes two trials used to support FDA approval of the diagnostic agent, including one on biochemical recurrence localization showing an overall detection rate of 75%, and another on primary nodal N1 staging that shows a sensitivity of 40% and a specificity of 95% for Ga 68 PSMA-11. Dr. Calais also notes the weaknesses of PSMA-11, including PET/CT’s inability to detect microscopic cancer cells, the way bone trauma in the ribs can lead to false positives, the challenge of accurately reading faint uptake lymph nodes, and how urine can disrupt analysis of the prostate fossa. Dr. Calais then compares PSMA against fluciclovine, finding that PSMA has a 30% higher detection rate; and against conventional imaging, finding that PSMA has a 27% higher rate of accuracy, as well as higher sensitivity and specificity. He also compares PSMA and local staging with MRI, highlighting a study on intra-prostatic tumor detection that shows a negligible difference in detection rates, as well as two studies on PSMA PET for biopsy guidance that show PSMA PET’s effectiveness in detecting especially challenging cancer. Dr. Calais concludes that PSMA PET/CT should replace other imaging modalities for prostate cancer staging and should be used as a complement to MRI for intra-prostatic tumor detection and staging.

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Next Generation Imaging for Prostate Cancer

by | Aug 2021

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, gives an overview of the current state of next generation imaging (NGI) for prostate cancer and how it compares to conventional imaging, i.e., bone scans and CT scans. He begins by noting that while there are strengths to conventional imaging and the NCCN clinical guidelines still recommend its use, it misses a lot of cancer, especially in patients with low PSA or biochemical recurrence (BCR). Dr. Koo suggests that NGI is to conventional imaging as a high-definition television is to a conventional one: both show a picture, but one shows a clearer one. He briefly looks at how NGI for prostate cancer works, explaining that NGI takes advantage of unique biological aspects of prostate cancer carcinogenesis and that increased metabolism and vascular changes in prostate cancer cells can be evaluated with radiolabeled analogs of choline, acetate, glucose, amino acids, and nucleotides. Dr. Koo then goes over the different approved NGI PET/CT options, including 11C-choline, 18F-fluciclovine, 68Ga-PSMA-11, and PyLARIFY PSMA. He particularly focuses on the 2 PSMA ligands, since data indicates that PSMA PET/CT performs better than anything used in the past, detecting more cancer at lower PSA levels than other techniques and in places where prostate cancer has rarely been seen before. Dr. Koo notes that PSMA is not infallible though, highlighting a study showing that while 68Ga-PSMA-11 generally has better detection rates than fluciclovine, fluciclovine has a higher detection rate in the prostate bed, suggesting that each radiopharmaceutical has its own strengths and weaknesses. He concludes with a summary of when and how clinicians should use NGI, emphasizing that NGI is here to stay and the field of urologic oncology should be prepared for rapid change.

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Urine Biomarkers for the Detection of Urothelial Carcinoma

Urine Biomarkers for the Detection of Urothelial Carcinoma

by | Jul 2021

Siamak Daneshmand, MD, Associate Professor of Urology and Director of Clinical Research at the University of Southern California discusses the ability of urinary markers to rule out bladder cancer and decrease the frequency of and need for cystoscopy and cytology. He goes over the limitations and adverse effects of cystoscopy and cytology before summarizing the findings of several studies looking at different urinary biomarkers for bladder cancer, including Cxbladder, Bladder EpiCheck, Bladder CARE™, and Decipher Bladder.

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