Purpose We examined the frequency of follow-up prostate-specific antigen (PSA) testing and prostate biopsy among men managed with active surveillance (AS) in academic and community urology practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). Materials and Methods MUSIC is a consortium of 42 practices that maintains a prospective clinical registry with validated clinical data for all patients diagnosed with prostate cancer at participating sites. We identified all patients in MUSIC practices who entered AS and had at least two years of continuous follow-up. After determining the frequency of repeat PSA testing and prostate biopsy, we calculated rates of concordance with NCCN guideline recommendations (i.e., at least three PSA tests and one surveillance biopsy) both collaborative-wide and across individual practices. Results We identified 513 patients entering AS from 1/2012–9/2013 with at least two years of follow-up. Among the 431 men (84%) that remained on AS for two years, 132 (30.6%) had follow-up surveillance testing at a frequency that was concordant with NCCN recommendations. At a practice-level, the median rate of guideline concordant follow-up was 26.5% (range 10–67.5%, p<0.001). Among patients with discordant follow-up, the absence of follow-up biopsy was common and not significantly different across practices (median rate=82.0%, p=0.35). Conclusions Among diverse community and academic practices in Michigan, there is wide variation in the proportion of men on active surveillance that meet guideline recommendations for follow-up PSA testing and repeat biopsy. These data highlight the need for standardized AS pathways that emphasize the role for repeat surveillance biopsies.

An intervention aimed at appropriate use of imaging was associated with decreased use of bone scans and computerized tomography among men at low risk for metastases.

By virtue of this work urologists have the opportunity to present specific recommendations from the panel to their individual patients. Community-wide efforts aimed at increasing rates of active surveillance and reducing practice and physician level variation in the choice of active surveillance vs treatment are warranted.

Purpose We compare pathologic outcomes following radical prostatectomy for a population-based sample of men with low-risk prostate cancer managed with initial active surveillance and delayed prostatectomy versus those treated with immediate surgery in order to better understand this expectant management approach outside of the context of academic cohorts. We hypothesized that delays in surgery due to initial surveillance would not impact surgical pathological outcomes. Material and Methods We performed a prospective cohort study of two groups of patients with National Comprehensive Cancer Network low-risk prostate cancer from practices in the Michigan Urological Surgery Improvement Collaborative (MUSIC): men who chose initial active surveillance and went on to delayed prostatectomy and those who chose immediate prostatectomy. Diagnoses occurred from January 2011 through August 2015. For these two groups, we compared radical prostatectomy Gleason scores, and rates of extra-prostatic disease, positive surgical margins, seminal vesicle invasion, and lymph node metastases. Results During median follow-up of 506 days, 79 (6%) of 1,359 low-risk men choosing initial surveillance transitioned to prostatectomy. Compared to those treated with immediate prostatectomy (n=778), men undergoing delayed surgery were more likely to have Gleason score ≥7 (69.2% vs 48.8% respectively, p=0.004), but no more likely to have positive margins, extra-prostatic extension, seminal vesicle invasion, or lymph node metastases. Conclusions Patients with low risk prostate cancer that enter active surveillance have higher grade disease at prostatectomy compared to those undergoing immediate surgery. However, the lack of differences in other adverse pathologic outcomes suggests preservation of the window of curability.

DNA was obtained from matching micro-dissected, primary tumor cells, paired metastases, and peripheral blood mononuclear cells (germline) from patients with appendiceal mucinous neoplasms. We compared specimens from patient cohorts comprising low-grade adenomucinous neoplasm versus high-grade mucinous adenocarcinoma using a targeted, amplicon sequencing panel of 409 cancer related genes (Ion Torrent Comprehensive Cancer Panel, Thermo-Fisher, Waltham, MA). Copy number variants, single nucleotide variants and small insertions/deletions were identified using a multiplex algorithm pipeline (GATK, VarScan2, MuTect2, SIFT, SIFT-INDEL, PolyPhen-2, Provean). There were significantly more damaging variants in high-grade versus low-grade tumor cohorts. Both cohorts contained damaging, heterozygous germline variants (catenin β1; notch receptor 1 and 4) in pathways associated with cell-lineage specification (WNT, NOTCH). Damaging, somatic KRAS proto-oncogene, GTPase mutations were present in both cohorts, while somatic GNAS complex locus mutations were confined to low-grade neoplasms. Variants predominantly affected transcription factors, kinases, and stem cell signaling molecules in canonical pathways including epithelial to mesenchymal transition, stem cell pluripotency, p53, PTEN, and NF-қB signaling pathways. High-grade tumors demonstrated MYC proto-oncogene, bHLH transcription factor (MYC) and death domain associated protein (DAXX) amplification and damaging somatic variants in tumor protein p53 (TP53), likely to amplify an aggressive phenotype. Damaging APC, WNT signaling pathway regulator (APC) deletions were identified in metastatic tissue of both cohorts suggesting a role in invasive disease. Our data suggest that germline dysregulation of WNT and/or NOTCH pathways predisposes patients toward a secretory cell phenotype (i.e., goblet-like cells) upon acquisition of somatic KRAS mutations. Additional somatically acquired variants activating oncogenes MYC and DAXX and inhibiting the critical tumor suppressor, tumor protein TP53, were consistent with manifestation of a high-grade phenotype. These additional changes within the epithelial to mesenchymal transition signaling network (WNT, NOTCH, RAS/ERK/PI3K, PTEN, NF-қB), produce aggressive high-grade tumor characteristics by actively driving cells towards dedifferentiation, proliferation, and migration.

In the Hospital Readmission Reduction Program (HRRP), the Centers for Medicare & Medicaid Services (CMS) utilizes a planned/unplanned algorithm to prevent hospitals from being penalized for scheduled rehospitalizations. We evaluated version 3.0 of the CMS planned readmission algorithm and hypothesized that some readmissions categorized as planned by the HRRP algorithm may actually be unplanned. We identified 143,054 index admissions and 16,116 thirty- day readmissions for 131 hospitals. Only 1252 readmissions were considered planned according to Medicare's readmission algorithm. The majority of these planned readmissions (723 [57.8%]) had an "emergent" or "urgent" admission type listed on the readmission claim, and many (513 [41.0%]) had emergency department charges, suggesting unanticipated returns to the hospital. HRRP should consider using the admission type variable and/or the presence of emergency department charges as a source of information when determining whether a readmission is planned or unplanned.

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A case is described of a successful radioguided forearm graft parathyroidectomy. This is the first report of both pre-operative diagnostic and successful intra-operative localisation during a single procedure, of autologous transplanted parathyroid tissue.