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892 OPTICAL BIOPSY OF UPPER TRACT UROTHELIAL CARCINOMA WITH CONFOCAL LASER ENDOMICROSCOPY
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THE JOURNAL OF UROLOGY姞
stage. Additionally, findings on URS were compared to surgical pathology reports to determine the ability of URS to accurately identify total number and locations of tumors. RESULTS: Eighty-one patients met inclusion criteria (mean age 69 yrs, range 41-92). Of 42 patients with high grade (HG) lesions on URS biopsy, 41 (98%) had HG tumors on final pathology. Conversely, only 23 of the 36 patients (64%) with low grade (LG) lesions on biopsy had LG tumors on final pathology. Fifty-two patients had Ta lesions on biopsy; of these, 50% remained Ta on final pathology while 50% were upstaged (50% T1, 17% T2, 6% T3/T4). Additionally, 19 patients had evidence of lamina propria invasion (T1) on biopsy without muscle present in specimen; only 1 of these (5%) remained T1 on final pathology while the remaining 18 (95%) were upstaged (37% T2, 53% T3, 5% T4). Overall, tumor mapping was accurate in 58 patients (72%). Lesions in the ureter were more commonly missed than those in the renal pelvis, occurring in 13 (16%) and 8 (10%) patients, respectively. In 16 of the 23 patients with missed lesions, the missed lesion was of higher grade then the biopsied lesion. CONCLUSIONS: URS with biopsy can accurately map UTUC in the majority of patients. However, more than a quarter of patients will have missed lesions, of which 70% represent a higher grade. Additionally, a third of patients initially believed to have LG lesions at biopsy actually have HG tumors. The presence of lamina propria invasion on URS biopsy should raise suspicion for muscle invasive disease. Based on these findings, at the time of URS every attempt should be made to map all lesions and biopsy all lesions seen.
Vol. 189, No. 4S, Supplement, Monday, May 6, 2013
CONCLUSIONS: We report the first in vivo microscopy of UTUC. Pending further clinical investigation, CLE may become a useful adjunct to UB and upper urinary tract surveillance.
Source of Funding: NIH R01 CA 160968 and Mauna Kea Technologies
Source of Funding: None
893 UPPER URINARY TRACT: ROLE OF PHOTODYNAMIC DIAGNOSIS
892 OPTICAL BIOPSY OF UPPER TRACT UROTHELIAL CARCINOMA WITH CONFOCAL LASER ENDOMICROSCOPY Daniel Bui*, Jen-Jane Liu, Timothy Chang, Shelly Hsiao, Ruchika Mohan, Kathleen Mach, Joseph Liao, Palo Alto, CA INTRODUCTION AND OBJECTIVES: The diagnosis of upper tract urothelial carcinoma (UTUC) is limited by variance in tumor sampling through ureteroscopic biopsy (UB). Advances in optical imaging technologies can potentially improve UTUC diagnosis and surveillance. We previously demonstrated optical biopsy of bladder cancer using probe-based confocal laser endomicroscopy (CLE). Dynamic in vivo microscopy of bladder tumors was achieved with 2.6 and 1.4-mm imaging probes passed through standard cystoscope working channels. In this study, we evaluated a new 0.85-mm imaging probe in the urinary tract and demonstrated feasibility and compatibility with standard ureteroscopes to achieve in vivo microscopy of UTUCs. METHODS: With IRB approval, six patients scheduled for transurethral resection of bladder tumor or diagnostic ureteroscopy were recruited. Patients received 0.5-1.0 mL of 10% fluorescein intravenously as previously described. CLE was performed with the Cellvizio® system (Mauna Kea Technologies, Paris France) using a 0.85mm-diameter probe (AQ-Flex 19), which has a resolution of 3.5 m and field of view (FOV) of 325 m. A 2.6-mm probe (GastroFlex UHD) with a resolution of 1 m and FOV of 240 m was also used in the bladder as previously described. Image acquisition with the 0.85-mm probe was achieved with standard rigid/flexible cystoscopes and semirigid/flexible ureteroscopes, while the 2.6-mm probe was used in conjunction with a rigid cystoscope. Acquired video sequences were analyzed after the procedure and compared with histopathological analysis. RESULTS: In vivo microscopy of the lower and upper urinary tract was successfully achieved using the 0.85-mm probe. Imaging of UTUC showed characteristic features including papillary structure, pleomorphism, and fibrovascular stalks (Fig 1). These features were reproducible in each of the UTUCs imaged (n⫽4). Lamina propria in normal renal pelvis and ureter were also identified. In comparison to the 2.6-mm probe, the 0.85-mm probe demonstrated lower resolution in identifying diagnostic features in the bladder.
Omar Aboumarzouk*, Cardiff, United Kingdom; Bhaskar Somani, Southampton, United Kingdom; Sarfraz Ahmad, Harry Moseley, Ghulam Nabi, Slawomir Kata, Dundee, United Kingdom INTRODUCTION AND OBJECTIVES: We aimed to assess the diagnostic accuracy of Photodynamic Diagnostic ureterorenoscopy in detection of Upper Urinary Tract Urothelial Cell Cancer and compare the results to that of white light ureterorenoscopy. METHODS: Between August 2007 and March 2012, 87 patients underwent Photodynamic Diagnostic flexible ureterorenoscopy for upper urinary tract tumours. Oral 5-Aminolevulinic Acid was used as a photosensitizer. The sensitivity, specificity, and detection rate of Photodynamic Diagnostic was calculated for both white light and blue light ureterorenoscopy. A comparison was conducted between the two investigations with P⬍0.05 considered significant using the Metaanalysis of Diagnostic and Screening Tests 1.4 programme. RESULTS: In total, 42.5% (37/87) patients had upper urinary tract lesions, of which PDD was able to detect 97.3% (36/37) of the abnormal tissue while white light detected 46% (17/37) of abnormal tissue (P⬍0.0001). PDD detected 10/37 superficial lesions (CIS and dysplasia) which were missed by white light ureterorenoscopy. The sensitivity, specificity, PPV, and NPV of PDD to detect abnormal tissue was 97%, 82%, 81%, and 98% compared to 46%, 86%, 71%, and 68% respectively. PDD was significantly more sensitive to detect tumours however no significantly difference was found in the specificity (P⬍0.0001 and 0.56 respectively). Eleven patients of the 87 (12.6%) developed side effects related to the 5-ALA, four patients developed a facial erythema and seven developed symptomatic hypotension, all the patients were treated conservatively with no long-term effects. CONCLUSIONS: PDD can safely be used in the upper urinary tract with a higher sensitivity and accuracy rate than standard white light ureterorenoscopy to detect upper urinary tract lesions. Furthermore, PDD was able to detect superficial lesions normally missed by standard white light.
THE JOURNAL OF UROLOGY姞
stage. Additionally, findings on URS were compared to surgical pathology reports to determine the ability of URS to accurately identify total number and locations of tumors. RESULTS: Eighty-one patients met inclusion criteria (mean age 69 yrs, range 41-92). Of 42 patients with high grade (HG) lesions on URS biopsy, 41 (98%) had HG tumors on final pathology. Conversely, only 23 of the 36 patients (64%) with low grade (LG) lesions on biopsy had LG tumors on final pathology. Fifty-two patients had Ta lesions on biopsy; of these, 50% remained Ta on final pathology while 50% were upstaged (50% T1, 17% T2, 6% T3/T4). Additionally, 19 patients had evidence of lamina propria invasion (T1) on biopsy without muscle present in specimen; only 1 of these (5%) remained T1 on final pathology while the remaining 18 (95%) were upstaged (37% T2, 53% T3, 5% T4). Overall, tumor mapping was accurate in 58 patients (72%). Lesions in the ureter were more commonly missed than those in the renal pelvis, occurring in 13 (16%) and 8 (10%) patients, respectively. In 16 of the 23 patients with missed lesions, the missed lesion was of higher grade then the biopsied lesion. CONCLUSIONS: URS with biopsy can accurately map UTUC in the majority of patients. However, more than a quarter of patients will have missed lesions, of which 70% represent a higher grade. Additionally, a third of patients initially believed to have LG lesions at biopsy actually have HG tumors. The presence of lamina propria invasion on URS biopsy should raise suspicion for muscle invasive disease. Based on these findings, at the time of URS every attempt should be made to map all lesions and biopsy all lesions seen.
Vol. 189, No. 4S, Supplement, Monday, May 6, 2013
CONCLUSIONS: We report the first in vivo microscopy of UTUC. Pending further clinical investigation, CLE may become a useful adjunct to UB and upper urinary tract surveillance.
Source of Funding: NIH R01 CA 160968 and Mauna Kea Technologies
Source of Funding: None
893 UPPER URINARY TRACT: ROLE OF PHOTODYNAMIC DIAGNOSIS
892 OPTICAL BIOPSY OF UPPER TRACT UROTHELIAL CARCINOMA WITH CONFOCAL LASER ENDOMICROSCOPY Daniel Bui*, Jen-Jane Liu, Timothy Chang, Shelly Hsiao, Ruchika Mohan, Kathleen Mach, Joseph Liao, Palo Alto, CA INTRODUCTION AND OBJECTIVES: The diagnosis of upper tract urothelial carcinoma (UTUC) is limited by variance in tumor sampling through ureteroscopic biopsy (UB). Advances in optical imaging technologies can potentially improve UTUC diagnosis and surveillance. We previously demonstrated optical biopsy of bladder cancer using probe-based confocal laser endomicroscopy (CLE). Dynamic in vivo microscopy of bladder tumors was achieved with 2.6 and 1.4-mm imaging probes passed through standard cystoscope working channels. In this study, we evaluated a new 0.85-mm imaging probe in the urinary tract and demonstrated feasibility and compatibility with standard ureteroscopes to achieve in vivo microscopy of UTUCs. METHODS: With IRB approval, six patients scheduled for transurethral resection of bladder tumor or diagnostic ureteroscopy were recruited. Patients received 0.5-1.0 mL of 10% fluorescein intravenously as previously described. CLE was performed with the Cellvizio® system (Mauna Kea Technologies, Paris France) using a 0.85mm-diameter probe (AQ-Flex 19), which has a resolution of 3.5 m and field of view (FOV) of 325 m. A 2.6-mm probe (GastroFlex UHD) with a resolution of 1 m and FOV of 240 m was also used in the bladder as previously described. Image acquisition with the 0.85-mm probe was achieved with standard rigid/flexible cystoscopes and semirigid/flexible ureteroscopes, while the 2.6-mm probe was used in conjunction with a rigid cystoscope. Acquired video sequences were analyzed after the procedure and compared with histopathological analysis. RESULTS: In vivo microscopy of the lower and upper urinary tract was successfully achieved using the 0.85-mm probe. Imaging of UTUC showed characteristic features including papillary structure, pleomorphism, and fibrovascular stalks (Fig 1). These features were reproducible in each of the UTUCs imaged (n⫽4). Lamina propria in normal renal pelvis and ureter were also identified. In comparison to the 2.6-mm probe, the 0.85-mm probe demonstrated lower resolution in identifying diagnostic features in the bladder.
Omar Aboumarzouk*, Cardiff, United Kingdom; Bhaskar Somani, Southampton, United Kingdom; Sarfraz Ahmad, Harry Moseley, Ghulam Nabi, Slawomir Kata, Dundee, United Kingdom INTRODUCTION AND OBJECTIVES: We aimed to assess the diagnostic accuracy of Photodynamic Diagnostic ureterorenoscopy in detection of Upper Urinary Tract Urothelial Cell Cancer and compare the results to that of white light ureterorenoscopy. METHODS: Between August 2007 and March 2012, 87 patients underwent Photodynamic Diagnostic flexible ureterorenoscopy for upper urinary tract tumours. Oral 5-Aminolevulinic Acid was used as a photosensitizer. The sensitivity, specificity, and detection rate of Photodynamic Diagnostic was calculated for both white light and blue light ureterorenoscopy. A comparison was conducted between the two investigations with P⬍0.05 considered significant using the Metaanalysis of Diagnostic and Screening Tests 1.4 programme. RESULTS: In total, 42.5% (37/87) patients had upper urinary tract lesions, of which PDD was able to detect 97.3% (36/37) of the abnormal tissue while white light detected 46% (17/37) of abnormal tissue (P⬍0.0001). PDD detected 10/37 superficial lesions (CIS and dysplasia) which were missed by white light ureterorenoscopy. The sensitivity, specificity, PPV, and NPV of PDD to detect abnormal tissue was 97%, 82%, 81%, and 98% compared to 46%, 86%, 71%, and 68% respectively. PDD was significantly more sensitive to detect tumours however no significantly difference was found in the specificity (P⬍0.0001 and 0.56 respectively). Eleven patients of the 87 (12.6%) developed side effects related to the 5-ALA, four patients developed a facial erythema and seven developed symptomatic hypotension, all the patients were treated conservatively with no long-term effects. CONCLUSIONS: PDD can safely be used in the upper urinary tract with a higher sensitivity and accuracy rate than standard white light ureterorenoscopy to detect upper urinary tract lesions. Furthermore, PDD was able to detect superficial lesions normally missed by standard white light.