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Renal oncocytoma and chromophobe renal cell carcinoma were accepted as unique renal tumors in the late 1990s. Since their formal description, criteria for diagnosis have evolved and additional distinct tumor subtypes originally considered as one these two entities are now recognized. The last two decades have witnessed unprecedented interest in the spectrum of low grade oncocytic renal neoplasms in three specific areas: (1) histologic characterization of tumors with overlapping morphologic features between oncocytoma and chromophobe renal cell carcinoma; (2) description of potentially unique entities within this spectrum, such as eosinophilic vacuolated tumor and low-grade oncocytic tumor; and (3) better appreciation of the association between a subset of low grade oncocytic tumors and hereditary renal neoplasia. While this important work has been academically rewarding, the proposal of several histologic entities with overlapping morphologic and immunophenotypic features (which may require esoteric adjunctive immunohistochemical and/or molecular techniques for confirmation) has created frustration in the diagnostic pathology and urology community as information evolves regarding classification within this spectrum of renal neoplasia. Pathologists, including genitourinary subspecialists, are often uncertain as to the "best practice" diagnostic approach to such tumors. In this review, we present a practical clinically relevant algorithmic approach to classifying tumors within the low grade oncocytic family of renal neoplasia, including a proposal for compressing terminology for evolving categories where appropriate without sacrificing prognostic relevance.

We sought to automate R.E.N.A.L. (for radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry scoring of preoperative computerized tomography scans and create an artificial intelligence-generated score (AI-score). Subsequently, we aimed to evaluate its ability to predict meaningful oncologic and perioperative outcomes as compared to expert human-generated nephrometry scores (H-scores).A total of 300 patients with preoperative computerized tomography were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer at a single institution. A deep neural network approach was used to automatically segment kidneys and tumors, and geometric algorithms were developed to estimate components of R.E.N.A.L. nephrometry score. Tumors were independently scored by medical personnel blinded to AI-scores. AI- and H-score agreement was assessed using Lin's concordance correlation and their predictive abilities for both oncologic and perioperative outcomes were assessed using areas under the curve.Median age was 60 years (IQE 51-68), and 40% were female. Median tumor size was 4.2 cm and 91.3% had malignant tumors, including 27%, 37% and 24% with high stage, grade and necrosis, respectively. There was significant agreement between H-scores and AI-scores (Lin's ⍴=0.59). Both AI- and H-scores similarly predicted meaningful oncologic outcomes (p0.001) including presence of malignancy, necrosis, and high-grade and -stage disease (p0.003). They also predicted surgical approach (p0.004) and specific perioperative outcomes (p0.05).Fully automated AI-generated R.E.N.A.L. scores are comparable to human-generated R.E.N.A.L. scores and predict a wide variety of meaningful patient-centered outcomes. This unambiguous artificial intelligence-based scoring is intended to facilitate wider adoption of the R.E.N.A.L. score.

To evaluate a conceptually simple model to predict new-baseline-glomerular-filtration-rate (NBGFR) after radical nephrectomy (RN) based on split-renal-function (SRF) and renal-functional-compensation (RFC), and to compare its predictive accuracy against a validated non-SRF-based model. RN should only be considered when the tumor has increased oncologic potential and/or when there is concern about perioperative morbidity with PN due to increased tumor complexity. In these circumstances, accurate prediction of NBGFR after RN can be important, with a threshold NBGFR 45 ml/min/1.73m236 RCC patients who underwent RN (2010-2012) with preoperative imaging (CT/MRI) and relevant functional data were included. NBGFR was defined as GFR 3-12 months post-RN. SRF was determined using semi-automated software that provides differential parenchymal-volume-analysis (PVA) from preoperative imaging. Our SRF-based model was: Predicted NBGFR = 1.24 (× Global GFRThe correlation-coefficients (r) were 0.87/0.72 for SRF-based/non-SRF-based models, respectively (p = 0.005). For prediction of NBGFR 45 ml/min/1.73mPrevious non-SRF-based models to predict NBGFR post-RN are complex and omit two important parameters: SRF and RFC. Our proposed model prioritizes these parameters and provides a conceptually simple, accurate, and clinically implementable approach to predict NBGFR post-RN. SRF can be easily obtained using PVA software that is affordable, readily available (FUJIFILM-Medical-Systems), and more accurate than nuclear-renal-scans. The SRF-based model demonstrates greater predictive-accuracy than a non-SRF-based model, including the clinically-important predictive-threshold of NBGFR 45 ml/min/1.73m

PURPOSE/OBJECTIVE(S) To determine if patients with unfavorable intermediate-risk (UIR), high-risk (HR), or very high-risk (VHR) prostate cancer (PCa) treated with 125I interstitial brachytherapy benefit from androgen deprivation therapy (ADT). MATERIALS/METHODS We reviewed our institutional database of patients with UIR, HR, or VHR PCa, per 2018 NCCN risk classification, treated with definitive 125I interstitial brachytherapy with or without ADT from 1998-2017. Outcomes including biochemical failure (bF), distant metastases (DM), and overall survival (OS) were analyzed with the Kaplan-Meier method and Cox proportional hazards regression. PCa-specific mortality (PCSM) was analyzed with Fine-Gray competing-risk regression. RESULTS Of 1033 patients, 262 (25%) received ADT and 771 (75%) did not. Median ADT duration was 6 months. By risk group, 764 (74%) patients were UIR, 219 (21%) HR, and 50 (5%) VHR. ADT was more frequently given to HR (50%) and VHR (56%) patients compared to UIR (16%; p

OBJECTIVE To analyze predictors, extent and functional implications associated with renal parenchymal volume replacement (PVR) by renal cell carcinoma (RCC) prior to intervention. This phenomenon is well-recognized yet not adequately studied, and, if severe, can influence management. MATERIALS AND METHODS A retrospective review was performed of partial nephrectomy (PN) and radical nephrectomy (RN) patients with available preoperative nuclear-renal-scan and imaging demonstrating solitary RCC with normal contralateral kidney. Normal renal parenchymal volume of each kidney was measured by free-hand scripting from preoperative axial images. Primary endpoint was percent PVR which was estimated assuming that the contralateral-kidney serves as a control: PVR = (volume contralateral kidney - volume ipsilateral kidney) normalized by volume contralateral kidney. Multivariable linear-regression analysis assessed factors associated with preoperative PVR. Further analysis evaluated the functional effect of PVR prior to surgery. RESULTS 146 PN and 136 RN patients with necessary studies were analyzed. For RN, the median PVR was 15% and a quarter of patients had PVR ≥27%. In contrast, PVR was negligible in PN patients for whom median preoperative parenchymal volumes were nearly identical in the ipsilateral/contralateral kidneys (179/180cc, respectively). PVR inversely correlated with preoperative renal function in the ipsilateral kidney (P

To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies.Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special emphasis was placed on contributions that changed perspectives about surgical management. Priority was also placed on randomized trials of off-clamp vs on-clamp cohorts.A decade ago, 'Every minute counts' was published, showing strong correlations between duration of ischaemia and development of acute kidney injury (AKI) and chronic kidney disease after clamped PN. This reinforced perspectives that ischaemia was the main modifiable factor that could be addressed to improve functional outcomes and helped spur efforts towards reduced or zero ischaemia PN. These approaches were associated with strong functional recovery and some peri-operative risk, although they were generally safe in experienced hands. Further research demonstrated that, when parenchymal volume changes were incorporated into the analyses, ischaemia lost statistical significance, and percent parenchymal volume saved proved to be the main determinant. Cold ischaemia was confirmed to be highly protective, and limited warm ischaemia also proved to be safe. The reconstructive phase of PN, with avoidance of parenchymal devascularization, appears to be most important for functional outcomes. Randomized trials of on-clamp vs off-clamp PN have shown minimal impact of ischaemia on functional recovery.The past decade has witnessed great progress regarding functional recovery after PN, with many lessons learned. However, there are still unanswered questions, including: What is the threshold of warm ischaemia at which irreversible ischaemic injury begins to develop? Are some cohorts at increased risk for AKI or irreversible ischaemic injury? and Which patients should be prioritized for zero-ischaemia PN?

Radical nephrectomy (RN) is an important consideration for the management of localized renal-cell-carcinoma (RCC) whenever the tumor appears aggressive, although reduced renal function is a concern. Split-renal-function (SRF) in the contralateral kidney and postoperative renal functional compensation (RFC) are fundamentally important for the accurate prediction of new baseline GFR (NBGFR) post-RN. SRF can be estimated either from nuclear renal scans (NRS) or from preoperative imaging using parenchymal-volume-analysis (PVA). We compare two SRF-based models for predicting NBGFR after RN with a subjective prediction of NBGFR by an experienced urologic-oncologist.187 RCC patients managed with RN (2006-16) were included based on the availability of preoperative CT/MRI and NRS, and preoperative/postoperative eGFR. NBGFR was defined as the final GFR 3-12 months post-RN. For the SRF-based approaches, SRF was derived from either NRS or PVA, and RFC was estimated at 25% based on previous independent analyses. Thus, the formula (Global GFRThe r values for subjective-assessment, NRS/SRF-based, and PVA/SRF-based approaches were 0.72/0.72/0.85, respectively (p 0.05). The PVA/SRF-based model also demonstrated significant improvement across other performance parameters.The PVA/SRF-based model more accurately predicts NBGFR post-RN than NRS/SRF-based and Subjective Estimation. PVA software (Fujifilm-medical-systems) is readily available and affordable and provides accurate SRF estimations from routine preoperative imaging. This novel approach may inform clinical management regarding RN/PN for complex RCC cases.

The American-Urological-Association(AUA) Guidelines for renal cancer(2017) recommend consideration for radical-nephrectomy(RN) over partial(PN) whenever there is increased oncologic-risk; and RN should be prioritized if three other criteria are all also met: 1) increased tumor-complexity; 2) no preexisting chronic-kidney-disease/ proteinuria, and 3) normal contralateral kidney that will likely provide estimated glomerular-filtration-rate (eGFR)45ml/min/1.73mRetrospective review of 267 consecutive RN/PN from 2019(100-RN/167-PN). High tumor-complexity was defined as R.E.N.A.L.≥9. Increased oncologic-risk was defined as tumor7cm, locally-advanced or infiltrative-features on imaging, or high-risk pathology on biopsy, if obtained. New-baseline GFR after RN was estimated using global-GFR, split-renal-function163 patients(61%) fit scenarios that are well-defined in the Guidelines. Of these, 34 had strong indications for RN, and all had RN. Twelve of 129 patients(9.3%) underwent RN despite Guidelines generally favoring PN. The remaining 104 patients(39%) did not fit within situations where the Guidelines provide specific recommendations. In these patients, RN was often performed despite functional-considerations favoring PN due to overriding concerns about oncologic-risk and/or tumor-complexity.Our data demonstrate complexity of decision-making about PN/RN as almost 40% of patients did not fit well-described AUA Guidelines descriptors. Compliance was generally strong although occasional overutilization of RN remains a concern in our series, and will be addressed with additional education. Further studies will be required to assess the generalizability of our findings in other institutions/settings.

ImportanceIdentifying hereditary cancer predisposition facilitates high-risk organ-specific cancer surveillance and prevention. In PTEN hamartoma tumor syndrome (PHTS), longitudinal studies remain lacking, and there are insufficient data on cancers in children and young adults, as well as individuals with neurodevelopmental disorders (NDD).ObjectiveTo evaluate lifetime cancer risks, including second malignant neoplasms (SMN), among patients with PHTS.Design, Setting, and ParticipantsProspective longitudinal cohort study (September 1, 2005, through January 6, 2022). General population risks from the Surveillance, Epidemiology, and End Results database. Patients with PHTS, molecularly defined as carrying germline PTEN variants, were accrued from community and academic medical centers throughout North America, South America, Europe, Australia, and Asia. Data were analyzed from July 2022 to February 2023.ExposuresReview of physical and electronic medical records, and follow-up through clinical visits or telephone interviews.Main Outcomes and MeasuresLifetime cancer risks in PHTS relative to the general population.ResultsA total of 7302 patients were prospectively accrued, 701 of whom had germline PTEN variants (median [IQR] age at consent, 38 [12-52] years; 413 female patients [59%]). Longitudinal follow-up data could be obtained for 260 patients (37%), with a median (IQR) follow-up of 4 (2-8) years. Of the 701 patients, 341 (49%) received at least 1 cancer diagnosis, with 144 (42%) of those having SMN. The study found significantly elevated lifetime risks for breast (91%), endometrial (48%), thyroid (33%), kidney (30%), and colorectal cancers (17%), as well as melanoma (5%). Cancer diagnoses were also observed in children and young adults with PHTS (15%) and in patients with PHTS with neurodevelopmental disorders (11%). Elevated risks (P P Conclusions and RelevanceThis cohort study found consistently elevated lifetime cancer risks in PHTS. Organ-specific surveillance should continue in patients with PHTS. Additional study is required to ascertain elevated cancer risks in patients with PHTS with NDD.

In a recent study of noise from a T-7A-installed GE F404 engine, microphones along 38 and 76 m (125 and 250 ft) arcs were mounted 1.5 m (5 ft) above the ground to quantify human impact. While helpful for this purpose, the resulting multipath effects pose challenges for other acoustical analyses. For jet noise runup measurements, these effects are complicated by the fact that the noise source is extended and partially correlated and its spatial properties are frequency dependent. Furthermore, a finite-impedance ground surface and atmospheric turbulence affect interference nulls. This study applies a ground-reflection method developed previously [Gee et al., Proc. Mtgs. Acoust. 22, 040001 (2014)] for rocket noise measurements. The model accounts for finite ground impedance, atmospheric turbulence, and extended source models that are treated as coherent and incoherent arrays of monopoles. Application to the ground runup data to correct the 38 and 76 m spectra at a range of angles suggests the incoherent line source model is more appropriate at sideline angles whereas the coherent source model is more appropriate for upstream and downstream propagation. Comparisons with near-field data and similarity spectra show that, while imperfect, this method represents an advancement in correcting jet noise spectra for ground reflection effects. [Work supported by ONR Grant No. N00014-21-1-2069.]

ANSI/ASA standard S12.75 (2012) provides guidance on allowable meteorological conditions for acoustical measurements of installed high-performance jet engines. This paper investigates meteorological effects on acoustic data acquisition by analyzing recent measurements of a T-7A-installed GE F404 engine. During this measurement, the aircraft was run up six times at engine powers from idle to full afterburner, with test conditions following those prescribed by S12.75. However, far-field spectra show variability between runs, despite relatively uniform test conditions. Measurements of the vertical temperature gradient show a correlation between the gradient and spectral characteristics. This analysis suggests that local temperature profiles must be considered more carefully in future full-scale measurements. [Work supported by ONR Grant No. N00014-21-1-2069.]

Investigation of weapons noise exposure outdoors necessitates including the impact of ground reflections. When analyzing the reflections’ impact on A-weighted equivalent level (LAeq), the contribution of the reflected waveform to the total level can often be acceptably modeled using a Friedlander equation-based source model and an ideal reflection based on the measurement geometry. However, the Friedlander model does not adequately model the negative phase of a gunshot waveform, making it inaccurate for locations where the waveform of the direct blast and the waveform of the reflection begin to overlap temporally. This merging of the waveforms for locations where the direct and ground-reflected path length difference is relatively small also makes it difficult to separate the waveforms and calculate the reflected wave’s contribution to noise exposure. As such, this paper investigates different approaches to estimating the contribution of the ground reflected wave to the LAeq, using direct and reflected waveforms in regions where they are well separated and then adjusting timing and amplitude for different geometries where merging takes place. Results reveal regions where the ground reflection contributes negligibly or even negatively to the total LAeq, which is not predicted by the Friedlander model nor by simple energy-addition approaches. [Work supported by Air Force Research Laboratory through Ball Aerospace Technology Corporation.]

Small caliber firearm (SCF) noise sources are typically impulsive in nature, possess a large amount of acoustic energy (consequently a large hearing damage risk), and are not omnidirectional. These sources are often operated in indoor shooting ranges where the potential for noise exposure risk is greater due to the reflective surfaces in the room. Indoor sound propagation models require inputs such as geometry, wall material properties, and some quantified source level description. One such room acoustic modeling technique is the Image-Source Method (ISM). ISM typically assumes specular reflections off the walls and represents those reflections as image sources. Many ISM algorithms can operate with high computational efficiency for simple omnidirectional source models, usually represented by a single quantity: sound power. However, ISM models using an omnidirectional source assumption can produce high errors in some scenarios involving highly directional sources, such as SCFs. In this work, an ISM algorithm has been modified to predict listener exposure levels from non-omnidirectional sources in complicated room designs, and has been validated against measured data from an SCF on an indoor Air Force shooting range.

The correct placement (height, orientation, and mounting techniques) for microphones used in standard data collection practices for aircraft environmental noise models is a topic of debate. Previous studies have demonstrated and quantified the dependence of spectral data recorded as a function of microphone placement variations and relative source origin. In this work, an in-depth investigation of microphone mounting effects is performed with an emphasis on (1) microphone height and (2) ground-mounting configuration for the purpose of quantifying ground run-up aircraft noise emissions for environmental noise model generation. Data for this investigation were collected on the T-7A Red Hawk in both standard (see ANSI S12.75-2012) and off-standard configurations for comparison.

In September 2021, an Atlas V rocket without solid rocket boosters was launched from Vandenberg Space Force Base, California, carrying the NASA/USGS Landsat 9 satellite. In this launch configuration, the plumes from the RD-180 engine’s two nozzles are unobstructed, providing the opportunity to analyze the sound generated by a liquid-fuel rocket engine with an azimuthally asymmetric nozzle geometry. Acoustical data were collected at various locations surrounding the launch pad, ranging from a few hundred meters to several kilometers. This paper discusses an overview of the measurement logistics, the types of analyses that may be performed using these data, and an initial analysis of the azimuthal variability of the overall sound pressure level and spectra.

Various types of low-cost acoustic recording equipment are available to the scientific community and the general public. While financial budgets can restrict what equipment can be purchased for a particular application, it is necessary to quantify the limitations of particular systems to determine their usefulness. Direct comparisons between recordings using low-cost equipment and using high fidelity equipment can highlight how the quality of low-cost recording is affected, which can help to determine whether or not budget recording systems are sufficient for a particular application. The Cornell Lab of Ornithology developed a low-cost terrestrial recording device for bioacoustic data collection known as the SwiftOne. This device can be set with various sampling rates and configurable recording schedules, making them suitable for long term data collection. Multiple SwiftOne units were used alongside a high-fidelity data acquisition system in both laboratory and outdoor data collection, including loudspeaker measurements in an anechoic chamber, ambient recordings at a bird refuge, and at a coastal rocket launch. The overall quality of the low-budget data recordings is investigated to determine the usefulness of the SwiftOne in these acoustic environments. Analyses include comparisons of measured waveforms, spectral content, and sound pressure levels.

Outdoor measurements of weapons noise exposure are influenced by ground reflections. This paper analyzes the reflections’ impact on A-weighted equivalent level (LAeq) for two measurement campaigns involving standing shooters and dozens of elevated microphones. Although it is only a marginally accurate model of a gunshot waveform, the modified Friedlander equation was used to model the direct and reflected muzzle blast waveforms over a perfectly reflective surface. The calculation of the reflection’s effect on LAeq indicates a 2–3 dB increase relative to the free-field contribution over a relatively large spatial range. Validation of this model for most locations where the measured direct and reflected waveforms was well separated yields acceptable agreement for LAeq (