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Dr. Sarah Chen
Stanford · NLP & interpretability
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Abstract Objectives The objective of this study is to evaluate whether prior Holmium laser enucleation of the prostate (HoLEP) affects the diagnostic accuracy of multiparametric prostate MRI (mpMRI) with PI‐RADS scoring for detecting clinically significant prostate cancer (csPCa) on biopsy. Patients and Methods We queried the Northwestern Electronic Data Warehouse for all patients who underwent mpMRI followed by prostate biopsy. Demographic information, mpMRI data including PI‐RADS score and biopsy data including Gleason grade (GG) were collected. Patients were stratified based on prior HoLEP and highest PI‐RADS score of index lesion on MRI. The outcome of interest was detection of csPCa (GG ≥ 2) on biopsy. Logistic regression was performed to assess the impact of prior HoLEP on the detection of csPCa at time of biopsy. Results A total of 8937 patients met inclusion criteria, of which 97 patients (1.1%) had prior HoLEP. HoLEP specimen revealed benign pathology in 38 patients (39.2%), GG1 in 32 patients (33.0%), GG2 in 25 patients (25.8%) and GG3 in 2 patients (2.1%). Average time from HoLEP to mpMRI was 11.5 months. The post‐HoLEP group had lower prostate volumes (median 25.0 vs. 47.0 cc; p < 0.001) and PSA density (median 0.06 vs. 0.12 ng/ml 2 ; p < 0.001). Rates of csPCa detection based on highest PI‐RADS score were comparable between control and HoLEP groups. Prior HoLEP did not significantly affect the detection of csPCa on multivariable analysis adjusting for age, race, PI‐RADS, family history of PCa, and PSA density (OR = 0.97; 95% CI: 0.60–1.57). Conclusion PI‐RADS remains a reliable predictor of csPCa after HoLEP despite anatomic alterations. mpMRI should continue to guide biopsy and risk stratification in this population, though larger validation is warranted.
BACKGROUND: Genomic biomarkers offer opportunities to improve risk stratification for patients with prostate cancer. We performed a transcriptomic profile of active surveillance (AS)-eligible patients who underwent radical prostatectomy (RP) to understand genomic associations with adverse pathologic features (APF) at RP. METHODS: Patients considered AS-eligible (NCCN low-favorable intermediate risk) but proceeded to RP from February 2012 to September 2024 were identified from our prospective institutional database. Outcomes were classified by presence or absence of APF at RP, which was defined as grade group (GG) ≥ 3, pT3b, or pN1 disease. Previously established genomic signatures of interest were compared between the two groups. Scaled multivariable logistic regression was performed to evaluate associations between multiple genomic classification systems and the outcome of APF. RESULTS: There were 184 AS-eligible patients, of whom 153 (83.2%) had favorable intermediate risk disease and 31 (16.8%) had low risk disease. There were 41 patients (22.3%) who had APF at RP. The incidence of favorable intermediate risk disease did not differ between those with and without APF (80.5% vs. 83.9%, p = 0.64). Patients with APF had a higher baseline PSA (5.6 ng/mL vs. 4.9 ng/mL, p = 0.01) and Decipher score (0.55 vs. 0.41, p = 0.004) compared to those without APF. On scaled logistic regression with adjustment for log-transformed PSA, the Decipher score, PTEN loss, activated CD4, and ERG positive rate were significantly associated with APF (OR 1.61, 95% CI 1.11-2.32, p = 0.01). Of ten other previously published genomic classifiers, nine were significantly associated with APF. CONCLUSION: AS-eligible patients with APF at RP demonstrate differences in gene expression when compared to those without APF. We established that multiple existing genomic classifiers not previously studied in this context demonstrate the ability to predict APF in this patient population. Inclusion of genomics in the risk stratification of AS-eligible patients has the potential to better inform clinical decisions.
American Journal of Respiratory and Critical Care Medicine · 2025-05-01
article
Abstract Tuberculous pleural effusion is a product of Mycobacterium tuberculosis (TB) infection in the lung pleura. It is generally diagnosed by demonstrating granuloma in the pleura or via elevated adenosine deaminase (ADA) in the pleural fluid[1]. Current therapy recommendation is a regimen of isoniazid, rifampin, and pyrazinamide for two months followed by isoniazid and rifampin for four months[1]. There is no documented recommendation regarding intrapleural fibrinolytic therapy for treatment of pleural tuberculosis[2]. A 40-year-old female from El Salvador presents with two weeks of fevers, chills, and myalgias. On initial work-up she is found to have a large right pleural effusion without overlying infiltrate. Bedside ultrasound and thoracic imaging (Figure 1) were concerning for moderate septations, and patient subsequently had a thoracostomy tube placed with 400cc fluid drained. Fluid studies indicated exudative effusion with LD 915, protein 4.8, and glucose 58 without organisms on pleural culture. Subsequently, they were treated with six doses of alteplase and dornase installations into the pleural cavity over three days. Testing revealed negative AFB smear, however positive TB PCR, ADA, and Quantiferon gold suggesting pleural tuberculosis. Further history revealed that the patient's family member whom she had contact with was exposed to tuberculosis in the past year. Our patient was started on RIPE antibiotic therapy and discharged from the hospital with isolation instructions and scheduled follow-up. Thereafter, in outpatient pulmonary clinic, she had ultrasound performed which suggested a remaining effusion along with potential consolidation. Further imaging revealed loculated right pleural effusion with concern for entrapped lung. Patient was taken for a right video-assisted thorascopic surgery (VATS) and decortication with thoracic surgery. During the procedure, she was noted to have areas of granulomatous peel instead of the expected fluid collection. She also required wedge resection of her middle lobe at that time due to visceropleural disruption. Ultimately, there is minimal data regarding the use of intrapleural fibrinolytics in pleural tuberculosis. A prior case study notes seven cases of tuberculosis pleuritis that received intrapleural lytics and achieved remission[3]. The novelty of this case relates to the use of intrapleural lytics complicated by recurrence of pleural effusion requiring VATS and wedge resection. Interestingly, the area of concern on imaging was not consistent with previously assumed fluid and instead was a thickened granulomatous peel. This development further mystifies if intrapleural lytic therapy is appropriate in the management of complicated tuberculosis pleuritis or if it leads to increased complications compared to standard therapy.
Objectives: To describe PSMA PET/CT characteristics of patients with high-risk BCR. Subjects/patients and methods: This was a retrospective analysis of patients with high-risk BCR prostate cancer (PSA ≥ 2 ng/ml above nadir after radiation therapy [RT] or ≥1 ng/ml after radical prostatectomy [RP] +/- RT) who underwent PET/CT from July 2021-March 2023. Patients with prior cytotoxic chemotherapy, androgen deprivation therapy (ADT) initiated >3 months prior to PET/CT or positive conventional imaging within 3 months of PET/CT were excluded. Neoadjuvant/adjuvant ADT completed ≥9 months prior was allowed. Logistic regression, Pearson's Chi-squared, Wilcoxon rank sum and Fisher's exact tests were used for analysis. Results: A total of 113 of 145 (77%) included patients in the analysis had ≥1 lesion on PSMA PET/CT. There was no difference in PSMA PET/CT positivity based on age, race, Gleason Grade at initial biopsy or PSA. Overall, 29 (20%) patients had lesions in the prostate/prostate bed only, 31 (21%) had lesions consistent with N1M0 disease and 53 (37%) had lesions consistent with M1 disease. For M1 patients, 21/53 (40%) had oligometastatic disease (1-3 lesions), and 32/53 (60%) had a higher burden (>3 lesions). Local recurrence was more common with RT and nodal recurrence with RP, with no difference in distant metastasis by initial treatment. Conclusion: Nearly 80% of patients with high-risk BCR after local treatment for prostate cancer with RP and/or RT will have positive findings on PSMA PET/CT. In addition to intensified systemic therapy, up to 55% of the patients may have benefitted from salvage local therapy, nodal pelvic radiation or metastasis-directed therapies for oligometastatic disease.
