Biopsy Cores Research Articles

Adherence to Synoptic Cancer Pathology Reporting Among Pathologists in the National Department of Veterans Affairs Health Care System

Context.— Quality communication between clinicians and pathologists is required for optimal cancer care. The College of American Pathologists provides anatomic site–specific cancer protocols that facilitate synoptic reporting for efficient communication, contributing to accuracy and completeness of cancer staging. Objective.— To evaluate synoptic cancer pathology reporting across the Department of Veterans Affairs (VA), the largest integrated health system in the United States, for 4 common cancers: melanoma and colon, bladder, and kidney cancer. Design.— For each cancer type, we investigated at least 200 biopsy and 200 resection reports from 2019 to 2021. In each report, we determined whether a synoptic format was used. The reports were selected using random sampling across all VA health care facilities. We also identified a set of core elements that were underdocumented. Results.— Among 1618 pathology reports, 778 (48%; 95% CI, 46%–50%) were synoptic reports. Synoptic reporting was much more common among resections (621 of 811; 77%; 95% CI, 74%–79%) than among biopsies (157 of 807; 19%; 95% CI, 17%–22%). It was most common in colorectal resections (200 of 206; 97%; 95% CI, 94%–99%) and least common in colon biopsy reports (1 of 200; 0.5%; 95% CI, 0%–3%). Core elements that were underdocumented included procedure and regional lymph nodes for resections of bladder and kidney cancer and of melanoma. Conclusions.— Synoptic reporting was used about three-quarters of the time for resections and about 1 in 5 times for biopsies. Future work should develop implementation strategies to improve synoptic reporting, especially for biopsy specimens and core elements that were relatively underdocumented.

A machine learning-based analysis for the definition of an optimal renal biopsy for kidney cancer

ObjectiveRenal Tumor biopsy (RTB) can assist clinicians in determining the most suitable approach for treatment of renal cancer. However, RTB's limitations in accurately determining histology and grading have hindered its broader adoption and data on the concordance rate between RTB results and final pathology after surgery are unavailable. Therefore, we aimed to develop a machine learning algorithm to optimize RTB technique and to investigate the degree of concordance between RTB and surgical pathology reports. Materials and methodsWithin a prospectively maintained database, patients with indeterminate renal masses who underwent RTB at a single tertiary center were identified. We recorded and analyzed the approach (US vs. CT), the number of biopsy cores (NoC), and total core tissue length (LoC) to evaluate their impact on diagnostic outcomes. The K-Nearest Neighbors (KNN), a non-parametric supervised machine learning model, predicted the probability of obtaining pathological characterization and grading. In surgical patients, final pathology reports were compared with RTB results. ResultsOverall, 197 patients underwent RTB. Overall, 89.8% (n=177) and 44.7% (n=88) of biopsies were informative in terms of histology and grading, respectively. The discrepancy rate between the pathology results from renal tissue biopsy (RTB) and the final pathology report following surgery was 3.6% (n=7) for histology and 5.0% (n=10) for grading. According to the machine learning model, a minimum of 2 cores providing at least 0.8 cm of total tissue should be obtained to achieve the best accuracy in characterizing the cancer. Alternatively, in cases of RTB with more than two cores, no specific minimum tissue threshold is required. ConclusionsThe discordance rates between RTB pathology and final surgical pathology are notably minimal. We defined an optimal renal biopsy strategy based on at least 2 cores and at least 0.8 cm of tissue or at least 3 cores and no minimum tissue threshold. Patients summaryRTB is a useful test for kidney cancer, but it's not always perfect. Our study shows that it usually matches up well with what doctors find during surgery. Using machine learning can make RTB even better by helping doctors know how many samples to take. This helps doctors treat kidney cancer more accurately.

Prostate cancer lesions in transition zone exhibit a higher propensity for pathological upgrading in radical prostatectomy.

The varying malignancy and lethality of different grades of prostate cancer (PCa) highlight the importance of accurate diagnosis. This study aims to evaluate the upgrading of transition zone (TZ) prostate cancer biopsies and identify factors to improve TZ biopsy accuracy. This retrospective study included 217 patients who underwent laparoscopic radical prostatectomy after 12 + X cores transperineal transrectal ultrasound-magnetic resonance imaging (MRI)-guided targeted prostate biopsy from 2018 to 2021 in our center. Patients with TZ lesions showed a higher incidence of International Society of Urological Pathology (ISUP) grade upgrading from 1 to higher grade compared to peripheral zone lesions (16.9% vs. 5.0%, p = 0.005). Multivariate analysis confirmed TZ lesions as an independent risk factor (OR: 4.594, 97.5% CI: 1.569-15.238, p = 0.008) for upgrading from 1 to higher. Additionally, the number of positive biopsy cores (OR: 0.586, 97.5% CI: 0.336-0.891, p = 0.029) and anterior TZ lesion location (OR: 10.797, 97.5% CI: 1.503-248.727, p = 0.048) were independent factors for the upgrading in TZ patients. This study found that PCa lesions located in the TZ, particularly the anterior TZ, have a higher risk of ISUP grade upgrading. This elevated risk arises from the insufficient distribution of biopsy cores around the TZ lesion. The findings underscore the importance of having an adequate number of biopsy cores around the lesion area to improve the accuracy of ISUP grade assessments.

Factors Affecting Biochemical Recurrence After Radical Prostatectomy and Validity of CAPRA Score in Predicting Biochemical Recurrence

Objective: Biochemical recurrence (BCR) after prostate cancer (PCa) treatment is undesirable. It is important to inform a patient about BCR in preoperative evaluation. We aimed to demonstrate the effectiveness of the (The Prostate Cancer Risk Assessment) CAPRA score used to predict this situation in our study. Material and Methods: The study included 348 patients who underwent Radical Prostatectony (RP) for localized PCa. Demographic, preoperative and postoperative data were collected. CAPRA score based on preoperative total PSA value, Gleason Score, clinical T stage, percentage of positive biopsy cores and age was calculated using these data. BCR was defined as a total PSA value >0.2 ng/dL for two consecutive times after RP. Follow-up periods, recurrence status and time of recurrence were recorded. Results: BCR positivity was detected in 60 (17.2%) of 348 patients. In univariate analyses, PSA level, lesion volume on MRI, ISUP grade, D’Amico risk classification, Seminal vesicule invasion (SVI) and CAPRA score were statistically significant in the groups. In multivariate analyses, PSA level, Neutrophile Lymphocyte Ratio, lesion dimension, intermediate risk according to D’amico classification, Extraprostatic extension (EPE) showed differences between both groups. The probability of biochemical progression-free in CAPRA risk groups shows a significant decrease in the probability of biochemical progression-free in the long term as risk increases in CAPRA risk groups: 91.4% in the low-risk group, 77.8% in the intermediate-risk group and only 61.7% in the high-risk group at 80-month follow-up. Conclusion: CAPRA scoring system should be supported by MpMRI findings and a new nomogram should be developed with these findings.

Role of Image-Guided Biopsy in Nonpalpable Breast Lesions: A Study in the Sub-Himalayan Region of North India

Background Nonpalpable breast lesions pose a challenge in their early diagnosis. Image-guided biopsy is preferred in these cases so that a pathological diagnosis of breast carcinoma is reached timely for a better prognosis as the disease has an increased chance of successful outcome with early identification and treatment. Objective The study aims at evaluating the role of stereotactic core needle biopsy (CNB) and percutaneous ultrasound-guided core needle biopsy (US-CNB) in diagnosing suspicious nonpalpable breast lesions. Methods Our study included 35 patients with nonpalpable breast lesions and having a Breast Imaging Reporting and Data System (BI-RADS) risk assessment category IV or V on mammography or sonography. These 35 lesions were subjected to percutaneous image-guided (stereotactic or US) biopsy for histopathological analysis. Results Out of a total of 35 cases, 17 were pathologically malignant (48.6%), with the most common subtype being invasive ductal carcinoma (82.3%). Twenty-nine cases underwent US-CNB, 16 (55.1%) of which were malignant and 13 (44.8%) were benign on histopathological evaluation (HPE). The remaining six cases, which on mammography showed no mass but suspicious malignant calcification only, were subjected to stereotactic CNB, out of which one (16.6%) was malignant and five (83.3%) were benign on HPE. Hence, the lesions visible on sonography were more likely to be malignant. Conclusion Sonography and mammography play a complimentary role in detecting breast carcinoma. Percutaneous biopsy under image guidance can be used as an accurate diagnostic alternative to open surgical excisional biopsy to avoid diagnostic delay.

The umblicus says it all

Abstract Introduction/Objective Umbilical nodules can be divided into benign and malignant. Malignant lesions of the umbilicus are very rare. They can arise from primary tumors or secondary to abdominal and pelvic malignancies. Literature review suggests that these umbilical lesions can present as primary tumor in 38% of the cases, endometriosis in 32%, and metastatic lesions in 30%. Umbilical metastasis is one of the main characteristic signs of extensive neoplastic disease and is known as Sister Mary Joseph’s nodule (SMJN). It is a very rare finding and the incidence of SMJN is 1- 3% in people diagnosed with intra-abdominal or pelvic malignancies. Methods/Case Report A 31-year-old male with no past medical history presented to the emergency room with 3 months history of umbilical nodule and 60 pounds weight loss. He experienced early satiety, abdominal pain, nausea and generalized fatigue. CT abdomen showed hepatomegaly with numerous hypoattenuating lesions throughout the liver with peripheral enhancement, and hypoattenuating mass within the pancreatic tail and body measuring approximately 2.1 x 5.8 cm that appears contiguous with hilar splenic lesion. CT chest showed multiple pulmonary metastases with prominent precarinal and subcarinal lymph nodes. Serologic tests revealed elevated Alpha fetoprotein, ALP, ALT, and CA19-9. Patient underwent umbilical nodule core biopsy and right liver core biopsy. Microscopic evaluation of the specimens revealed pancreatic acinic cell carcinoma with two different morphological variants. Umbilical nodule with glandular pattern and liver lesion with trabecular pattern. Immunohistochemical stains were performed with tumor cells positive for CK 7, Trypsin and BCL-10 and negative for Glypican 3, CK 20, AFP and CD56. The prognosis is poor, with an average survival time of about 19 months. After the diagnosis patient underwent chemotherapy. Results (if a Case Study enter NA) NA Conclusion Umbilical nodules can be diagnosed with careful clinical and histopathological evaluation. The prognosis of patients presenting with SMJN is generally poor as it is a sign of advanced malignancy. Sometimes it may be the first and only sign of an internal neoplasm. Therefore, this is an important differential diagnosis to consider.

Solid-basaloid Variant of Mammary Adenoid Cystic Carcinoma – Report of an Unusual Case with Literature Review

Abstract Introduction/Objective Adenoid cystic carcinoma (AdCC) of breast is a rare subtype of malignancy, constituting approximately 0.1% of all breast carcinomas. The solid-basaloid variant (SB-AdCC) is exceedingly uncommon. Here, we present such an unusual case of SB-AdCC. Methods/Case Report A 64-year-old woman who underwent screening mammography presented with abnormal findings, revealing a hypoechoic ovoid, lobulated nodule at 7:00 of the left breast, which prompted an ultrasound- guided biopsy. Histologically, the biopsy cores demonstrated a 9 mm infiltrative round, solid nests with focal “cribriforming” areas. It was composed of monomorphic basaloid epithelial cells with marked nuclear atypia and high mitotic count. High-grade ductal carcinoma in situ, solid papillary carcinoma, and nonspecific invasive carcinoma were in differentials. Immunohistochemical (IHC) staining expressed positivity for CD117 and CK 5/6, while p63, SMMHC, and synaptophysin were negative. MYB gene rearrangement confirmed by fluorescence in situ hybridization. As expected, the tumor lacked ER, PR, and HER2 expression by IHC. Left breast mastectomy and axillary lymph node dissection have been scheduled. Results (if a Case Study enter NA) NA Conclusion Per literature review, the mean age of SB-AdCC at diagnosis was 68 years (33-84 years) with an average tumor size of 25 mm (12-70 mm). It had more aggressive behavior, with a higher propensity for lymph node metastasis, locally recurrence, and distant metastasis. The median disease-free survival was 46.5 months versus 151.8 months in those with class AdCC. Notably, neovascularization has emerged as a strong independent predictor of outcome in SB-AdCC. Most patients were treated with surgical excision, axillary lymph node dissection, and/or adjuvant chemotherapy. Limited studies demonstrated that neoadjuvant chemotherapy may induce an excellent response. Furthermore, a distinct molecular mutation enriched in NOTCH and CREBBP genes has been identified, which could be novel potential therapeutic target. Thus, awareness of this extremely rare breast cancer subtype and accurate differentiation from other entities are paramount for appropriate management strategies.

Is Confirmatory Biopsy Still Necessary for Active Surveillance of Men With Grade Group 1 Prostate Cancer in the Era of Multiparametric Magnetic Resonance Imaging?

Men diagnosed with prostate cancer (PCa) considering active surveillance (AS) are recommended confirmatory biopsy (CBx). Whether this is necessary in the era of MRI-informed biopsies is questionable. We studied men with Grade Group [GG] 1 PCa at diagnostic biopsy (DBx) considering AS who underwent MRI and CBx (systematic + targeted) within 18 months. Outcomes were grade reclassification to GG ≥ 2, GG ≥ 3, and reclassification to unfavorable intermediate risk disease (UIR). Subset analyses were performed for men with (1) MRI prior to DBx and (2) MRI after DBx. Five hundred twenty-two men had GG1 PCa at DBx. At CBx, 20% reclassified to GG ≥ 2, 12% to UIR, and 5.6% to GG ≥ 3. Of the 306 with positive MRI (PI-RADS > 3), 27% reclassified to GG ≥ 2 and 16% to UIR disease; men with negative MRI experienced these outcomes at rates of 9.2% and 5.5%. There were no differences in reclassification outcomes based on MRI timing (group A vs B), and neither PSA density nor prostate volume added to MRI information. In men with MRI targets, approximately 1/3 of GG > 2 reclassification events were only captured by systematic biopsy core(s). Reclassification rates at CBx were high in men with positive MRI, but < 10% for all reclassification outcomes in men with negative MRI (95% CI 5.8%-14% for GG > 2, 2.9%-10% for UIR, 0.8%-5.3% for GG > 3). Our data support systematic + targeted CBx for men with positive MRI considering AS, while men with GG1 cancer and negative MRI should be able to defer CBx.

Concordance Between the Expert Reading of Biparametric-MRI and the Nonexpert Multiparametric-MRI for the Detection of Clinically Significant Prostate Cancer: Clinical Implications

PurposeProstate-magnetic resonance imaging (MRI) interpretation is challenging, with expertise playing a crucial role. Biparametric MRI (bpMRI) is gaining popularity in experienced centers due to its time and cost advantages over multiparametric MRI (mpMRI). We aim to analyze concordance between nonexpert radiologist PI-RADS from mpMRI and expert radiologist PI-RADS from bpMRI, and its clinical implications. Material and Methods222 men suspected of having prostate cancer (PCa) and mpMRI reported by nonexpert radiologists were referred to a reference center for transperineal MRI-TRUS fusion biopsy where an expert radiologist reported bpMRI PI-RADS 2.1 and segmentation, blinded to external mpMRI. Mapping targeted suspected lesions and 12-core systematic biopsies were performed. Clinically significant PCa (csPCa) was diagnosed when ISUP-grade group was ≥2. ResultsConcordance between both PI-RADS existed in 49.1% of cases (Kappa index 0.288). In 102 cases (45.9%), expert reclassification to lower PI-RADS existed, while an increase existed in 11 cases (5.0%), P < .001. Agreement existed in 30.8% of nonexpert PI-RADS 3, 43.6% of PI-RADS 4, and 83.7% of PI-RADS 5, P < .001. Potential clinical implications included 27% reduction in prostate biopsies when using expert bpMRI readings compared to nonexpert mpMRI readings (P < 0.001), while undetected csPCa were 4.2% and 3.4%, respectively, P = .669. Over-detection reduction of insignificant PCa was 29.4% and 0%, respectively, P = .034. ConclusionsConcordance between nonexpert PI-RADS mpMRI and expert PI-RADS bpMRI was low, increasing with nonexpert PI-RADS. Expert reclassification would reduce prostate biopsies by more than one quarter and over-detection of iPCa, while csPCa detection remained similar.

Factors influencing urinary retention following freehand transperineal prostate biopsy: Insights from a tertiary care center study

ABSTRACT Objectives: In this study, we evaluated the risk factors for urinary retention after freehand transrectal ultrasound (TRUS) guided transperineal prostate biopsy (TPB). Patients and Methods: Data from 102 cases of freehand TPB at a single institution were retrospectively collected and analyzed. All patients underwent magnetic resonance imaging (MRI)-TRUS cognitive fusion TPB using a transperineal needle guide, with systematic biopsies from 10 prostate sectors and additional MRI-guided targeted biopsies. Exclusions comprised patients with coagulation abnormalities, prior prostate surgeries including biopsy, active urinary tract infection, or a lack of pre-biopsy multiparametric MRI. Results: 14/102 (13.72%) had urinary retention and required urethral catheterization for voiding difficulty or discomfort along with a bladder volume of ≥500 ml. Patients with retention exhibited significantly larger prostate volumes (median 75 cc vs. 40 cc; P &lt; 0.05). Receiver operating curve analysis revealed a prostate volume threshold of 57.5 cc and a core number cutoff of 23 for predicting post-TPB urinary retention, with sensitivities of 78.57% and 85.71%, specificities of 75% and 82.95%, positive predictive values of 33.33% and 44.44%, and negative predictive values of 95.75% and 97.33%, respectively, whereas the number of biopsy cores correlated positively with the development of urinary retention (median 25 vs. 22; P &lt; 0.05). Urinary retention was independent of the patient’s age, comorbidities, presenting prostate-specific antigen levels, prebiopsy severity of lower urinary tract symptoms, and use of alpha-blockers. Conclusion: Patients with larger prostates and higher number of biopsy cores are at a higher risk of postfreehand TPB urinary retention and should receive appropriate counselling. Targeted biopsies alone, rather than a full template, may help mitigate urinary retention in these high-risk groups.

Determining Long-term Prostate Cancer Outcomes for Active Surveillance Patients Without Early Disease Progression: Implications for Slowing or Stopping Surveillance

Background and objectiveActive surveillance (AS) of prostate cancer (PCa) is the standard of care for low-grade disease, but there is limited guidance on tailoring protocols for stable patients. We investigated long-term outcomes for patients without initial progression and risk factors for upgrade. MethodsMen on AS with Gleason grade group (GG) 1 PCa on three serial biopsies, ≥5 yr without progression, and ≥10 yr of follow-up were included. Outcomes were upgrade (GG ≥2), major upgrade (GG ≥3), progression to treatment, metastasis, PCa-specific survival, and overall survival. Cox proportional hazards regression models were used to estimate the associations between patient characteristics and risk of upgrade. Key findings and limitationsA total of 774 men met the inclusion criteria. At 10, 12, and 15 yr, upgrade-free survival rates were 56%, 45%, and 21%; major upgrade–free survival rates were 88%, 83%, and 61%; treatment-free survival rates were 86%, 83%, and 73%; metastasis-free survival rates were 99%, 99%, and 98%; and overall survival rates were 98%, 96%, and 95%, respectively. PCa-specific survival was 100% at 15 yr. On a multivariable analysis, year of diagnosis, age, body mass index (BMI), and biopsy core positivity were associated with upgrade (all p < 0.01), whereas age and prostate-specific antigen (PSA) density were associated with major upgrade. Conclusions and clinical implicationsPatients without progression for 5 yr on AS had modest rates of upgrade and low rates of metastasis, and mortality at 15 yr of follow-up. Year of diagnosis, older age, increased BMI, and increased biopsy core positivity were associated with upgrade, whereas older age and greater PSA density were associated with an increased risk of major upgrade. A subset of these patients may benefit from deintensification of AS protocols. Patient summaryThere are little reported data or clinical guidelines for patients with prostate cancer (PCa) who are stable for many years on active surveillance (AS). We show, in a large cohort, that PCa patients without progression for 5 yr on AS have modest rates of upgrade and very low rates of metastasis, and mortality rates at 15 yr of follow-up, and that older age, increased body mass index, and increased PCa volume are associated with an increased likelihood of future upgrade. This study supports continued AS in this patient population and deintensification in select patients.

Upgrading of Grade Group 1 Prostate Cancer at Prostatectomy: Germline Risk Factors in a Prospective Cohort.

Localized prostate tumors show significant spatial heterogeneity, with regions of high-grade disease adjacent to lower-grade disease. Consequently, prostate cancer biopsies are prone to sampling bias, potentially leading to underestimation of tumor grade. To study the clinical, epidemiologic and molecular hallmarks of this phenomenon, we conducted a prospective study of grade upgrading: differences in detected prostate cancer grade between biopsy and surgery. We established a prospective, multi-institutional cohort of men with Grade Group 1 (GG1) prostate cancer on biopsy who underwent radical prostatectomy. Upgrading was defined as detection of GG2+ in the resected tumor. Germline DNA from 192 subjects was subjected to whole-genome sequencing to quantify ancestry, pathogenic variants in DNA damage response genes and polygenic risk. Of 285 men, 67% upgraded at surgery. PSA density and percent of cancer in pre-prostatectomy positive biopsy cores were significantly associated with upgrading. No assessed genetic risk factor was predictive of upgrading, including polygenic risk scores for prostate cancer diagnosis. In a cohort of low-grade prostate cancer patients, a majority upgraded at radical prostatectomy. PSA density and percent of cancer in pre-prostatectomy positive biopsy cores portended the presence of higher-grade disease, while germline genetics was not informative in this setting. Patients with low-risk prostate cancer, but elevated PSA density or percent cancer in positive biopsy cores, may benefit from repeat biopsy, additional imaging or other approaches to complement active surveillance. Further risk stratification of patients with low-risk prostate cancer may provide useful context for active surveillance decision-making.

Incorporation of mpMRI before prostate biopsy shall be universal or selective: A prospective observational study

Purpose: The aim of this study is to evaluate the role of multiparametric magnetic resonance imaging (mpMRI) as a triage workup in the diagnostic pathway of suspected prostate cancer (PCa) in our population. Material and methods: This prospective observational study was conducted at lesser than details of site are removed for blinded peer review &gt; on biopsy-naive patients from May 2021 to December 2022. We included patients aged 40 to 80 years with clinical suspicion of PCa, prostate-specific antigen (PSA) level &gt;4 ng/mL, abnormal digital rectal examination (DRE), or all the above. All patients first underwent 1.5-T mpMRI and transrectal ultrasound-guided biopsy using the cognitive biopsy technique. Results: A total of 95 patients were included, with the majority of them (64.21%) being ≥66 years old. Of these, 69 patients had abnormal DRE findings, 89 had PSA ≥4 ng/mL, and 64 had both elevated PSA and abnormal DRE findings. PCa was detected in 6.25%, 54.84%, 71.43%, and 96.43% of patients with lesions of Prostate Image Reporting and Data System scores of 2, 3, 4, and 5, respectively. Using Prostate Image Reporting and Data System score of 3 as a biopsy threshold resulted in high sensitivity (98.31%) and low specificity (41.67%) for PCa detection. The proportion of Gleason score of ≥7 cancer-detected cores in the magnetic resonance imaging-guided cognitive biopsy was significantly higher than that in the standard 12-core biopsy (86.54% versus 61.45%; P &lt; 0.001). Conclusion: The incorporation of prebiopsy mpMRI could be used as a diagnostic pathway for suspected PCa before transrectal ultrasound-guided biopsy.

Image-guided multiparametric magnetic resonance imaging-transrectal ultrasound fusion biopsy augmented with a sextant versus an extended template random biopsy: Comparison of cancer detection rates, complication and functional outcomes.

To compare the efficacy of a novel fusion template "reduced six-core systemic template and multiparametric magnetic resonance imaging/transrectal ultrasound (mpMRI/TRUS) fusion targeted biopsy" (TBx+6c), with mpMRI/TRUS fusion-targeted biopsy and 12-core systematic biopsy template (TBx+12c) in the diagnosis of prostate cancer (PCa). This is an institutional review board approved single-center observational study involving adult men undergoing fusion-targeted biopsies for the diagnosis of PCa. Patients were sorted into cohorts of TBx+6c or TBx+12c based on the systematic biopsy template used. The study's main objective was to determine the cancer detection rate (CDR) for overall PCa and clinically significant PCa (csPCa) and the secondary objectives were to compare complication rates and functional outcome differences between the cohort. A total of 204 patients met study's inclusion criteria. TBx+6c group had 120 patients, while TBx+12c cohort had 84 patients. The groups had similar baseline characteristics and overall CDR in the TBx+6c cohort was 71.7% versus 79.8%, compared to the TBx+12c (p = 0.18) whereas, the csPCa detection rate in the TBx+6c group was 50.8% versus 54.8% in the TBx+12c group (p = 0.5). TBx+6c cohort had lower overall complication rate of 3% versus 13%, (p = 0.01) and ≥ grade 2 complication rates (1 (1%) vs. 3(4%), p = 0.03) compared to the TBx+12c cohort. There were no differences in IIEF-5 (p = 0.5) or IPSS (p = 0.1) scores at baseline and 2-weeks and 6-weeks post-biopsy. TBx+6c cohort, when compared to the TBx+12c cohort, demonstrated comparable diagnostic performance along with similar functional outcomes and lower complication rates. These results suggest the importance of further exploring the clinical implications of adopting a TBx+6c schema for PCa diagnosis in comparison to the widely used TBx+12c schema through a multicenter randomized controlled trial.

Targeted Prostate Biopsy: How, When, and Why? A Systematic Review.

Prostate cancer, the second most diagnosed cancer among men, requires precise diagnostic techniques to ensure effective treatment. This review explores the technological advancements, optimal application conditions, and benefits of targeted prostate biopsies facilitated by multiparametric magnetic resonance imaging (mpMRI). A systematic literature review was conducted to compare traditional 12-core systematic biopsies guided by transrectal ultrasound with targeted biopsy techniques using mpMRI. We searched electronic databases including PubMed, Scopus, and Web of Science from January 2015 to December 2024 using keywords such as "targeted prostate biopsy", "fusion prostate biopsy", "cognitive prostate biopsy", "MRI-guided biopsy", and "transrectal ultrasound prostate biopsy". Studies comparing various biopsy methods were included, and data extraction focused on study characteristics, patient demographics, biopsy techniques, diagnostic outcomes, and complications. mpMRI-guided targeted biopsies enhance the detection of clinically significant prostate cancer while reducing unnecessary biopsies and the detection of insignificant cancers. These targeted approaches preserve or improve diagnostic accuracy and patient outcomes, minimizing the risks associated with overdiagnosis and overtreatment. By utilizing mpMRI, targeted biopsies allow for precise targeting of suspicious regions within the prostate, providing a cost-effective method that reduces the number of biopsies performed. This review highlights the importance of integrating advanced imaging techniques into prostate cancer diagnosis to improve patient outcomes and quality of life.

Cowper Glands Identified in Prostate and Urethral Specimens: A Comprehensive Immunohistochemical Characterization and Potential Diagnostic Pitfall.

Cowper glands recognition remains one of the key histoanatomic benign mimics of prostatic adenocarcinoma. In most instances, these can be identified based on the dimorphic population of lobulated acini and duct(s). However, in the prostate biopsy setting with incomplete/distorted cores, this may not be immediately apparent and may warrant use of immunohistochemistry to argue against prostatic adenocarcinoma. Although immunohistochemical pitfalls in Cowper glands have been described, to our knowledge a comprehensive evaluation of both traditional and purportedly prostate-specific novel markers in Cowper glands has not been previously performed. Herein, we studied the clinicopathological and immunohistochemical features of 21 male patients (age range 39-81 years; mean = 63 years), including 15 prostate biopsies (7 of which also had prostate cancer in the same specimen set and 2 of which had both prostate cancer and Cowper glands in the same biopsy core). Immunohistochemistry showed the following results in Cowper glands: 100% positive for NKX3.1, 100% positive (basal cells) for both high molecular weight keratin and p63, 57% positive for PSAP, 25% positive for PSMA, 5% positive for AMACR, and 0% positive for PSA. In conclusion, for specimens lacking appreciable dimorphic morphology, caution should be rendered when using prostate-specific markers (PSA, PSAP, PSMA, and NKX3.1) as these can show considerable staining in Cowper glands and be a pitfall. Instead, findings from this cohort indicate relying on basal markers (high molecular weight keratin/p63; either individually or in a "cocktail" approach) and PSA are most useful in distinguishing Cowper glands (retained basal cell markers staining) from prostatic adenocarcinoma.

Can the Briganti 2019 nomogram be modified to predict lymph node metastasis risk in patients with prostate cancer detected with in-bore biopsy?

We aimed to modify the Briganti 2019 nomogram and to test whether it is valid for patients who were diagnosed with prostate cancer through in-bore prostate biopsies. Data for 204 patients with positive multiparametric prostate MRI and prostate cancer identified either by mpMRI-cognitive/software fusion or in-bore biopsy and who underwent robot-assisted radical prostatectomy and extended pelvic lymph node dissection between 2012 and 2023 were retrospectively analyzed. The Briganti 2019 nomogram was applied to the mpMRI-cognitive/software fusion biopsy group (142 patients) in the original form, and then, two modifications were tested for the targeted component. Original and modified scores were compared. These modifications were adapted for the in-bore biopsy group (62 patients). The final histopathologic stage was regarded as the gold standard. Nodal metastases were identified in 18/142 (12.6%) of mpMRI-cognitive/software fusion biopsy patients and 8/62 (12.9%) of the in-bore biopsy patients. In the mpMRI-cognitive/software fusion biopsy group, tumor size/core size (%) of targeted biopsy cores and positive core percentage on systematic biopsy were significant parameters for lymph node metastasis based on univariate logistic regression analyses (p < 0.05). With the modifications of these parameters for the in-bore biopsy group, V1 modification of the Briganti 2019 nomogram provided 100% sensitivity and 31.5% specificity (AUC:0.627), while V2 modification provided 75% sensitivity and 46.3% specificity (AUC:0.645). Briganti 2019 nomogram may be modified by utilizing tumor size/core size (%) for targeted biopsy cores instead of positive core percentage on systematic biopsy or by not taking both parameters into consideration to detect node metastasis risk of patients diagnosed with in-bore biopsies.

The learning curve for transperineal MRI/TRUS fusion prostate biopsy: A prospective evaluation of a stepwise approach

ObjectiveTo evaluate the learning curve of a transperineal (TP) magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) fusion prostate biopsy (PBx). Materials and MethodsConsecutive patients undergoing MRI followed by TP PBx from May/2017 to January/2023, were prospectively enrolled (IRB# HS-13-00663). All participants underwent MRI followed by 12 to 14 core systematic PBx (SB), with at least 2 additional targeted biopsy (TB) cores per PIRADS ≥3. The biopsies were performed transperineally using an organ tracking image-fusion system. The cohort was divided into chronological quintiles. An inflection point analysis was performed to determine proficiency. Operative time was defined from insertion to removal of the TRUS probe from the patient's rectum. Grade Group ≥2 defined clinically significant prostate cancer (CSPCa). Statistically significant if P < 0.05. ResultsA total of 370 patients were included and divided into quintiles of 74 patients. MRI findings and PIRADS distribution were similar between quintiles (P = 0.08). The CSPCa detection with SB+TB was consistent across quintiles: PIRADS 1 and 2 (range, 0%–18%; P = 0.25); PIRADS 3 to 5 (range, 46%–70%; P = 0.12). The CSPCa detection on PIRADS 3 to 5 TB alone, for quintiles 1 to 5, was respectively 44%, 58%, 66%, 41%, and 53% (P = 0.08). The median operative time significantly decreased for PIRADS 1 and 2 (33 min to 13 min; P < 0.01) and PIRADS 3 to 5 (48 min to 19 min; P < 0.01), reaching a plateau after 156 cases. Complications were not significantly different across quintiles (range, 0–5.4%; P = 0.3). ConclusionsThe CSPCa detection remained consistently satisfactory throughout the learning curve of the Transperineal MRI/TRUS fusion prostate biopsy. However, the operative time significantly decreased with proficiency achieved after 156 cases.

Establishing a model predicting Gleason grade group upgrading in prostate cancer.

Gleason grade group (GG) upgrading is associated with increased biochemical recurrence (BCR), local progression, and decreased cancer-specific survival (CSS) in prostate cancer (PCa). However, descriptions of the risk factors of GG upgrading are scarce. The objective of this study was to identify risk factors and establish a model to predict GG upgrading. There were 361 patients with PCa who underwent radical prostatectomy between May 2011 and February 2022 enrolled. Univariate and multivariate logistic regression analyses were identified and nomogram further narrowed down the contributing factors in GG upgrading. The correction curve and decision curve were used to assess the model. In the overall cohort, 141 patients had GG upgrading. But the subgroup cohort (GG ≤2) showed that 68 patients had GG upgrading. Multivariate logistic regression analysis showed that in the overall cohort, total prostate-specific antigen (tPSA) ≥10 ng/mL, systemic immune-inflammation index (SII) >379.50, neutrophil-lymphocyte ratio (NLR) >2.13, the GG of biopsy ≥3, the number of positive cores >3 were independent risk factors in GG upgrading. In the cohort of biopsy GG ≤2, multivariate logistic regression showed that the tPSA ≥10 ng/mL, SII >379.50 and the number of positive cores >3 were independent risk factors in GG upgrading. A novel model predicting GG upgrading was established based on these three parameters. The area under the curve (AUC) of the prediction model was 0.759. The C-index of the nomogram was 0.768. The calibration curves of the model showed good predictive performance. Clinical decision curves indicated clinical benefit in the interval of 20% to 90% of threshold probability and good clinical utility. Combined levels of tPSA, SII and the positive biopsy cores distinguish patients with high-risk GG upgrading in the group of biopsy GG ≤2 and are helpful in the decision of treatment plans.

Risk factors for Gleason score upgrade from prostate biopsy to radical prostatectomy.

Accurate identification of prostate cancer Gleason grade group remains an important component of the initial management of clinically localized disease. However, Gleason score upgrading (GSU) from biopsy to radical prostatectomy can occur in up to a third of patients treated with surgery. Concern for disease undergrading remains a source of diagnostic uncertainty, contributing to both over-treatment of low-risk disease as well as under-treatment of higher-risk prostate cancer. This review examines the published literature concerning risk factors for GSU from time of biopsy to prostatectomy final pathology. Risk factors identified for Gleason upgrading include patient demographic and clinical factors including age, body mass index, race, prostate volume, and biomarker based assays, including prostate-specific antigen (PSA) density, and testosterone values. In addition, prostate magnetic resonance imaging (MRI) findings have also been associated with GSU. Biopsy-specific characteristics associated with GSU include lower number of biopsy cores and lack of targeted methodology, and possibly increasing percent biopsy core positivity. Recognition of risk factors for disease undergrading may prompt confirmatory testing including repeat sampling or imaging. Continued refinements in imaging guided biopsy techniques may also reduce sampling error contributing to undergrading.