Optimizing cystoscopy and TURBT: enhanced imaging and artificial intelligence.

Diagnostic cystoscopy in combination with transurethral resection of the bladder tumour are the standard for the diagnosis, surgical treatment and surveillance of bladder cancer. The ability to inspect the bladder in its current form stems from a long chain of advances in imaging science and endoscopy. Despite these advances, bladder cancer recurrence and progression rates remain high after endoscopic resection. This stagnation is a result of the heterogeneity of cancer biology as well as limitations in surgical techniques and tools, as incomplete resection and provider-specific differences affect cancer persistence and early recurrence. An unmet clinical need remains for solutions that can improve tumour delineation and resection. Translational advances in enhanced cystoscopy technologies and artificial intelligence offer promising avenues to overcoming the progress plateau.

Tumor detection under cystoscopy with transformer-augmented deep learning algorithm.

Objective.Accurate tumor detection is critical in cystoscopy to improve bladder cancer resection and decrease recurrence. Advanced deep learning algorithms hold the potential to improve the performance of standard white-light cystoscopy (WLC) in a noninvasive and cost-effective fashion. The purpose of this work is to develop a cost-effective, transformer-augmented deep learning algorithm for accurate detection of bladder tumors in WLC and to assess its performance on archived patient data.Approach.'CystoNet-T', a deep learning-based bladder tumor detector, was developed with a transformer-augmented pyramidal CNN architecture to improve automated tumor detection of WLC. CystoNet-T incorporated the self-attention mechanism by attaching transformer encoder modules to the pyramidal layers of the feature pyramid network (FPN), and obtained multi-scale activation maps with global features aggregation. Features resulting from context augmentation served as the input to a region-based detector to produce tumor detection predictions. The training set was constructed by 510 WLC frames that were obtained from cystoscopy video sequences acquired from 54 patients. The test set was constructed based on 101 images obtained from WLC sequences of 13 patients.Main results.CystoNet-T was evaluated on the test set with 96.4 F1 and 91.4 AP (Average Precision). This result improved the benchmark of Faster R-CNN and YOLO by 7.3 points in F1 and 3.8 points in AP. The improvement is attributed to the strong ability of global attention of CystoNet-T and better feature learning of the pyramids architecture throughout the training. The model was found to be particularly effective in highlighting the foreground information for precise localization of the true positives while favorably avoiding false alarmsSignificance.We have developed a deep learning algorithm that accurately detects bladder tumors in WLC. Transformer-augmented AI framework promises to aid in clinical decision-making for improved bladder cancer diagnosis and therapeutic guidance.

An Efficient Framework for Video Documentation of Bladder Lesions for Cystoscopy: A Proof-of-Concept Study.

Processing full-length cystoscopy videos is challenging for documentation and research purposes. We therefore designed a surgeon-guided framework to extract short video clips with bladder lesions for more efficient content navigation and extraction. Screenshots of bladder lesions were captured during transurethral resection of bladder tumor, then manually labeled according to case identification, date, lesion location, imaging modality, and pathology. The framework used the screenshot to search for and extract a corresponding 10-seconds video clip. Each video clip included a one-second space holder with a QR barcode informing the video content. The success of the framework was measured by the secondary use of these short clips and the reduction of storage volume required for video materials. From 86 cases, the framework successfully generated 249 video clips from 230 screenshots, with 14 erroneous video clips from 8 screenshots excluded. The HIPPA-compliant barcodes provided information of video contents with a 100% data completeness. A web-based educational gallery was curated with various diagnostic categories and annotated frame sequences. Compared with the unedited videos, the informative short video clips reduced the storage volume by 99.5%. In conclusion, our framework expedites the generation of visual contents with surgeon's instruction for cystoscopy and potential incorporation of video data towards applications including clinical documentation, education, and research.

Spontaneous cell fusions as a mechanism of parasexual recombination in tumour cell populations.

The initiation and progression of cancers reflect the underlying process of somatic evolution, in which the diversification of heritable phenotypes provides a substrate for natural selection, resulting in the outgrowth of the most fit subpopulations. Although somatic evolution can tap into multiple sources of diversification, it is assumed to lack access to (para)sexual recombination-a key diversification mechanism throughout all strata of life. On the basis of observations of spontaneous fusions involving cancer cells, the reported genetic instability of polypoid cells and the precedence of fusion-mediated parasexual recombination in fungi, we asked whether cell fusions between genetically distinct cancer cells could produce parasexual recombination. Using differentially labelled tumour cells, we found evidence of low-frequency, spontaneous cell fusions between carcinoma cells in multiple cell line models of breast cancer both in vitro and in vivo. While some hybrids remained polyploid, many displayed partial ploidy reduction, generating diverse progeny with heterogeneous inheritance of parental alleles, indicative of partial recombination. Hybrid cells also displayed elevated levels of phenotypic plasticity, which may further amplify the impact of cell fusions on the diversification of phenotypic traits. Using mathematical modelling, we demonstrated that the observed rates of spontaneous somatic cell fusions may enable populations of tumour cells to amplify clonal heterogeneity, thus facilitating the exploration of larger areas of the adaptive landscape (relative to strictly asexual populations), which may substantially accelerate a tumour's ability to adapt to new selective pressures.

Optical biopsy of penile cancer with in vivo confocal laser endomicroscopy.

INTRODUCTION: Surgical management of penile cancer depends on accurate margin assessment and staging. Advanced optical imaging technologies may improve penile biopsy and organ-sparing treatment. We evaluated the feasibility of confocal laser endomicroscopy for intraoperative assessment of benign and malignant penile tissue. PATIENTS AND METHODS: With institutional review board approval, 11 patients were recruited, 9 with suspected penile cancer, and 2 healthy controls. Confocal laser endomicroscopy using a 2.6-mm fiber-optic probe was performed at 1 or 2 procedures on all subjects, for 13 imaging procedures. Fluorescein was administered intravenously approximately 3 minutes prior to imaging for contrast. Video sequences from in vivo (n = 12) and ex vivo (n = 6) imaging were obtained of normal glans, suspicious lesions, and surgical margins. Images were processed, annotated, characterized, and correlated with standard hematoxylin and eosin histopathology. RESULTS: No adverse events related to imaging were reported. Distinguishing features of benign and malignant penile tissue could be identified by confocal laser endomicroscopy. Normal skin had cells of uniform size and shape, with distinct cytoplasmic membranes consistent with squamous epithelium. Malignant lesions were characterized by disorganized, crowded cells of various size and shape, lack of distinct cytoplasmic membranes, and hazy, moth-eaten appearance. The transition from normal to abnormal squamous epithelium could be identified. CONCLUSIONS: We report the initial feasibility of intraoperative confocal laser endomicroscopy for penile cancer optical biopsy. Pending further evaluation, confocal laser endomicroscopy could serve as an adjunct or replacement to conventional frozen section pathology for management of penile cancer.