Anterior Peripheral Zone Research Articles

Clinicopathologic Significance of Anterior Prostate Cancer: Comparison With Posterior Prostate Cancer in the Era of Multiparametric Magnetic Resonance Imaging.

Anterior prostate cancer (APC) has been considered an indolent tumor, most commonly arising in the transition zone (TZ). More recently, detection of APC has been facilitated through multiparametric magnetic resonance imaging and improved biopsy techniques, enabling earlier detection. The pathologic features and clinical significance of pure APC in a large contemporary series of well-characterized tumors have, to date, not been elucidated. Cases with APC defined as cancer present anterior to the urethra only were identified from 1761 consecutive radical prostatectomy specimens accessioned between January 2015 and August 2016. The clinicopathologic features of these cases were compared with those of pure posterior prostate cancer (PPC) and the features of anterior peripheral zone (APZ) cancers were compared with those of TZ cancers. In addition, the tumor series from 2015 to 2016 was compared with a cohort of 1054 patients accessioned before the utilization of multiparametric magnetic resonance imaging in the routine workup of patients with prostate cancer. In the 2015-2016 series, there were 188 (10.7%) patients with APC compared with 5.4% in the series from the pre-multiparametric magnetic resonance imaging era. No difference was observed between APC and PPC with regards to patient age or mean serum prostate-specific antigen at presentation. Mean tumor volume and positive surgical margin (PSM) rates were significantly higher in APC. In contrast, PPC was more commonly high grade with more frequent extraprostatic extension (EPE). None of the cases of APC had infiltration of the seminal vesicle or lymph node involvement, in contrast to PPC, with almost 14% of cases in each category. The 3- and 5-year biochemical recurrence-free survival was significantly higher in APC when compared with PPC, although this was not retained on multivariable analysis which included tumor location. On division of APCs according to anatomic zone of origin, 45% were APZ cancer and 37% TZ cancer. On comparison of APZ and TZ cancers, there were no significant differences in mean age and serum prostate-specific antigen at presentation as well as tumor volume, Gleason score, and PSM rate. High-grade malignancy (Gleason score >3 + 4=7) was seen in 26% of TZ cancers which compared with 44% of APZ cancers and 56% of PPC cancers. The rate of EPE was significantly higher in APZ when compared with TZ cancer ( P< 0.0005); however, the biochemical recurrence rate was not significantly different between the groups. The prevalence of APC in radical prostatectomy specimens has increased in recent times, in association with earlier detection at a stage amenable to curative surgical treatment. APC, when compared with PPC, is less commonly high grade with less frequent EPE, despite the APC group having larger tumors and a higher PSM rate at presentation. However, not all anterior cancers are indolent. Anterior cancers are more commonly seen in the APZ than the TZ and APZ cancers appear more locally aggressive than TZ cancers.

Impact of Zone of Origin in Anterior Dominant Prostate Cancer: Long-Term Biochemical Recurrence-Free Survival in an Anatomically Well-Characterized Cohort.

Our goal was to determine whether zonal origin of anterior dominant prostate cancers is associated with clinical outcome among patients treated with radical prostatectomy. We investigated the clinical outcomes of 197 patients with previously well-characterized anterior dominant prostatic tumors on radical prostatectomy. Univariable Cox proportional hazards models were used to test for an association between anterior peripheral zone (PZ) or transition zone (TZ) tumor location and clinical outcomes. Zonal origin of anterior dominant tumors: 97/197 (49%) anterior PZ, 70 (36%) TZ, 14 (7%) both zones and 16 (8%) indeterminate zone. Comparing anterior PZ and TZ tumors, there were no significant differences in Grade group, incidence of extraprostatic extension or surgical margin positivity rate. Overall, 19 (9.6%) patients experienced biochemical recurrence (BCR), including 10 with anterior PZ origin and 5 with TZ origin. Median followup time among those without BCR was 9.5 years (IQR 7.2, 12.7). BCR-free survival at 5 and 10 years was 91% and 89% for anterior PZ tumors, and 94% and 92% for TZ tumors, respectively. On univariate analysis, there was no evidence of a difference in time to BCR between anterior PZ and TZ tumor zone of origin (p=0.5). In this anatomically well-characterized cohort of anterior dominant prostate cancers, long-term BCR-free survival was not significantly associated with zone of origin. Future studies utilizing zone of origin as a parameter should consider separating anterior and posterior PZ localization, as outcomes may differ.

Natural Orifice Transluminal Endoscopic Partial Prostatectomy: A Real-time Image-guided Focal Extirpative Feasibility Study

To assess the feasibility of focal endoscopic excision of prostate cancer (PCa) under guidance of real-time magnetic resonance imaging (MRI) or magnetic ultrasound fusion (MUF). Using a cadaveric model, multifocal PCa was simulated using 2 MRI-compatible fiducial markers. These were inserted transrectally and used to generate regions of interests (ROIs) on a 1.5-T surface-coil MRI. The first marker was placed in the right mid-peripheral zone (ROI 1), and the second marker was placed in the left seminal vesicle as a referent lesion for subsequent imaging. MRI of the specimen was then obtained. The radiologist created ROIs using fusion biopsy system at each marker. Two additional incidental ROIs were identified in the left transitional zone (ROI 2-suspicious for benign prostatic hyperplasia nodule) and in the right anterior peripheral zone (ROI 3-suspicious for PCa). Holmium laser enucleation of the transitional zone of the prostate was performed to gain access to the peripheral zone lesions. MUF was used during endoscopic laser excision to convey targeting accuracy. The cadaver was then reimaged to determine the adequacy of resection and examined for histopathologic correlation. Real-time MUF imaging identified the target lesions consistently at the locations designated as ROIs. Complete endoscopic resection of ROIs was possible. Repeated MUF imaging and the postprocedure MRI confirmed the completeness of resection. Pathologic examination demonstrated complete excision, intact neurovascular bundles, and posterior prostatic capsule. This approach may represent a new minimally invasive frontier for focal surgical resection of PCa, making histopathologic margin status determination possible.

638 - Diagnostic performance of multiparametric MRI in prostate cancer: Per core analysis of three prospective ultrasound/MRI fusion biopsy datasets

Clinicopathologic parameters of the anterior index tumor and other tumor foci were assessed and compared to non-APC in the same cohort. Previous biopsy information was correlated with RP. RESULTS: Of the 467 patients in this cohort, 72 (15%) had APC: 50 in the anterior peripheral zone (APZ, 69%); 10 in the transitional zone (TZ, 14%); and 12 involving both the APZ and TZ (17%). 25 APC were single tumors (35%), and the rest were multifocal. Clinicopathologic information was available for 72 APC patients and 308 non-APC patients and is compared in Table 1. 15% of APC patients demonstrated a primary Gleason pattern 4 or higher, and 21% had extraprostatic extension (EPE) present. None of the APC, including the high-grade (GS>7) cases, demonstrated seminal vesicle invasion (SVI). 10 APC had a positive surgical margin (13%), most commonly at the apex or base. 56 APCwere preceded by an extended biopsy (78%), while 2 APC had only sextant biopsy (3%) and 14 APC were identified after a combination of extended and perineal saturation biopsies (19%). APC was present on significantly fewer cores and with less tumor involvement of the core. APC patients frequently (54%) had a higher GS or novel Gleason pattern 5 at RP than at biopsy. Distribution of preoperative serum PSA levels was similar between APC and non-APC patients. CONCLUSIONS: APC demonstrate distinct clinicopathologic features (including absence of SVI) and are frequently under-graded and minimally sampled at the time of biopsy. These unique characteristics may have a clinical impact on detection (i.e., need for saturation biopsy) and suitability for inclusion in active surveillance protocols. Future longterm studies are needed to determine the outcome of patients with APC.

V11-01 REAL-TIME IMAGE GUIDED FOCAL SURGICAL RESECTION FOR PROSTATE CANCER: A FEASIBILITY STUDY

You have accessJournal of UrologyAdrenal/Single Port Surgery/LESS/NOTES1 Apr 2016V11-01 REAL-TIME IMAGE GUIDED FOCAL SURGICAL RESECTION FOR PROSTATE CANCER: A FEASIBILITY STUDY Haidar Abdul-Muhsin, Akira Kawashima, Alvin Silva, Melissa Stanton, Gianni Moshero, Erik Castle, Paul Andrews, and Mitchell Humphreys Haidar Abdul-MuhsinHaidar Abdul-Muhsin More articles by this author , Akira KawashimaAkira Kawashima More articles by this author , Alvin SilvaAlvin Silva More articles by this author , Melissa StantonMelissa Stanton More articles by this author , Gianni MosheroGianni Moshero More articles by this author , Erik CastleErik Castle More articles by this author , Paul AndrewsPaul Andrews More articles by this author , and Mitchell HumphreysMitchell Humphreys More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1818AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Focal therapy of prostate cancer is a management strategy for localized disease whereby ablative energy is delivered to targeted portions of the prostate to minimize morbidity. The basic tenant of current technologies is that they rely on cellular destruction with no histopathological correlation to ensure completeness and accuracy of treatment. The aim of this experiment was to assess the feasibility of real time MRI/US fusion technology to guide focal surgical therapy of prostate cancer. METHODS In a cadaveric model multi-focal prostate cancer was simulated using two 3x1mm MRI-compatible fiducial markers (PolymarkTM from CIVCO medical solution, Coralville, IA, USA) that could not be seen on ultrasound. These were used to generate regions of interests (ROIs) on a 1.5 T surface coil MRI. The first marker was placed in the right peripheral zone at the mid gland (ROI 1) and the second marker was placed in the left seminal vesicle (ROI 2) as a referent for subsequent MRI imaging. A limited multiparametric MRI of the specimen was done after maker placement and following focal surgical excision. The radiologist created ROIs using UroNavTM fusion biopsy system (Invivo, Gainsville, FL, USA) at each marker as well as two additional ROIs that represented intrinsic lesions seen on imaging: the left transitional zone, ROI 3 (suspicious for BPH nodule) and in the right anterior peripheral zone, ROI 4 (suspicious for prostate cancer). The following steps were performed: 1. Holmium laser resection of transitional zone BPH nodule, ROI 3. 2. Holmium Laser enucleation of the prostate (HoLEP) to gain access to the peripheral zone. 3. Repeat MRI/US fusion imaging to confirm the locations of the remaining ROIs after HoLEP. 4. Laser resection of the ROIs 1 and 4. 5. Repeat MRI/US fusion to confirm the absence of the targeted ROIs followed by a final confirmatory MRI Real time MRI/US fusion imaging identified the target lesions consistently at the locations designated as ROIs on the MRI. Using focal surgical therapy it was possible to completely resect each ROI (with the exception of the SV) leaving the majority of the prostate intact. Repeated MRI/US fusion imaging and the post procedure MRI confirmed the complete resection of our targeted lesions. There was no significant fluid extravasation that interfered with successful imaging during the procedure. RESULTS Real time MRI/US fusion imaging identified the target lesions consistently at the locations designated as ROIs. Using focal surgical therapy it was possible to completely resect each ROI (with the exception of the SV) leaving the majority of the prostate intact. Repeated MRI/US fusion imaging and the post procedure MRI confirmed the complete resection of our targeted lesions. There was no significant fluid extravasation that interfered with successful imaging during the procedure. CONCLUSIONS Real time MRI/US fusion technology can be used to guide focal surgical therapy of prostate cancer. Additional effort to standardize the procedure and examine the reproducibility is necessary, but this may represent a new frontier for focal surgical resection of prostate cancer. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1003 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Haidar Abdul-Muhsin More articles by this author Akira Kawashima More articles by this author Alvin Silva More articles by this author Melissa Stanton More articles by this author Gianni Moshero More articles by this author Erik Castle More articles by this author Paul Andrews More articles by this author Mitchell Humphreys More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP19-10 CAN MAGNETIC RESONANCE/ULTRASOUND FUSION IMAGING TECHNOLOGY BE USED FOR REAL TIME IMAGE GUIDANCE DURING FOCAL SURGICAL THERAPY FOR PROSTATE CANCER? A FEASIBILITY STUDY.

You have accessJournal of UrologyImaging/Radiology: Uroradiology III1 Apr 2016MP19-10 CAN MAGNETIC RESONANCE/ULTRASOUND FUSION IMAGING TECHNOLOGY BE USED FOR REAL TIME IMAGE GUIDANCE DURING FOCAL SURGICAL THERAPY FOR PROSTATE CANCER? A FEASIBILITY STUDY. Haidar Abdul-Muhsin, Akira Kawashima, Alvin Silva, Melissa Stanton, Gianni Moshero, Erik Castle, Paul Andrews, and Mitchell Humphreys Haidar Abdul-MuhsinHaidar Abdul-Muhsin More articles by this author , Akira KawashimaAkira Kawashima More articles by this author , Alvin SilvaAlvin Silva More articles by this author , Melissa StantonMelissa Stanton More articles by this author , Gianni MosheroGianni Moshero More articles by this author , Erik CastleErik Castle More articles by this author , Paul AndrewsPaul Andrews More articles by this author , and Mitchell HumphreysMitchell Humphreys More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2758AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiparametric magnetic resonance imaging (mMRI) opened up a new frontier in the management of prostate cancer. The most common application to date is the fusion with ultrasound images to provide real time targeted guidance during prostate biopsies. However, the potential of this technology to determine the limits of surgical intervention has not been previously assessed to provide real time guidance in focal surgical therapy METHODS In a cadaveric model, multi-focal localized prostate cancer was simulated using two 3x1mm MRI-compatible fiducial markers (PolymarkTM from CIVCO medical solution, Coralville, IA, USA). These were used to generate regions of interests (ROIs) on a 1.5 T surface coil MRI. The first marker was placed in the right peripheral zone at the mid gland (ROI 1) and the second marker was placed in the left seminal vesicle (ROI 2) as a referent for subsequent MRI imaging. A limited mMRI of the specimen was done after marker placement and following focal surgical excision. The radiologist created ROIs using UroNavTM fusion biopsy system (Invivo, Gainsville, FL, USA) at each marker as well as two additional ROIs that represented intrinsic lesions seen on imaging: the left transitional zone, ROI 3 (suspicious for benign prostate hyperplasia nodule) and the right anterior peripheral zone, ROI 4 (suspicious for prostate cancer). The procedure was done in the following sequence: First, Holmium laser resection of transitional zone BPH nodule, ROI 3. Second, Holmium Laser enucleation of the prostate (HoLEP) was performed to gain access to the peripheral zone. Third, a repeat MRI/US fusion imaging was done to confirm the locations of the remaining ROIs after HoLEP followed by Laser enucleation (ROIs 1 and 4). Finally the MRI/US fusion imaging was repeated to confirm the absence of the targeted ROIs which was followed by a final confirmatory mMRI RESULTS There was some image distortion with the initial MRI/US fusion imaging that resolved on subsequent imaging attributed to dehydration of the cadaver. Real time MRI/US fusion imaging consistently identified the target lesions during the procedure at the locations designated as ROIs. Successful demonstration of image confirmation during resection of the targeted lesions during the procedure was possible and was confirmed with post procedural MRI CONCLUSIONS Real time MRI/US fusion technology can be used to guide focal surgical therapy in the prostate. Additional effort to standardize the procedure and examine the reproducibility is necessary © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e207 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Haidar Abdul-Muhsin More articles by this author Akira Kawashima More articles by this author Alvin Silva More articles by this author Melissa Stanton More articles by this author Gianni Moshero More articles by this author Erik Castle More articles by this author Paul Andrews More articles by this author Mitchell Humphreys More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP48-17 ANTERIOR PROSTATE CANCER: CLINICOPATHOLOGIC CHARACTERIZATION WITH BIOPSY CORRELATION

MP48-17 ANTERIOR PROSTATE CANCER: CLINICOPATHOLOGIC CHARACTERIZATION WITH BIOPSY CORRELATION

TMPRSS2–ERG rearrangement in dominant anterior prostatic tumours: incidence and correlation with ERG immunohistochemistry

To study prostate cancer zonal differences in TMPRSS2-ERG gene rearrangement. We examined 136 well-characterized dominant anterior prostatic tumours, including 61 transition zone (TZ) and 75 anterior peripheral zone (PZ) lesions, defined using strict anatomical considerations. TMPRSS2-ERG FISH and ERG protein immunohistochemistry were performed on tissue microarrays. FISH results, available for 56 TZ and 71 anterior PZ samples, were correlated with ERG staining and TZ-associated 'clear cell' histology. Fewer TZ cancers (four of 56; 7%) were rearranged than anterior PZ cancers (18 of 71; 25%) (P = 0.009); deletion was the sole mechanism of TZ cancer rearrangement. ERG protein overexpression was present in 4% (two of 56; both FISH+) and 30% (21 of 71; 17 FISH+) of TZ and anterior PZ tumours, respectively. 'Clear cell' histology was present in 21 of 56 (38%) TZ and eight of 71 (11%) anterior PZ tumours. Seven per cent of cancers with and 21% without this histology had rearrangement, regardless of zonal origin. TMPRSS2-ERG rearrangement occurs in dominant TZ and anterior PZ prostate cancers, with all rearranged TZ cancers in this cohort showing deletion. ERG immunohistochemistry demonstrated excellent sensitivity (86%) and specificity (96%) for TMPRSS2-ERG rearrangement. TMPRSS2-ERG fusion is rare in TZ tumours and present at a low frequency in tumours displaying 'clear cell' histology.

1341 CHARACTERISTICS OF ANTERIOR PREDOMINANT PROSTATE CANCER AND THE USEFULNESS OF MULTIPARAMETRIC MRI IN DIAGNOSIS

You have accessJournal of UrologyProstate Cancer: Localized (VI)1 Apr 20131341 CHARACTERISTICS OF ANTERIOR PREDOMINANT PROSTATE CANCER AND THE USEFULNESS OF MULTIPARAMETRIC MRI IN DIAGNOSIS Sahyun Pak, Sejun Park, Sang Hoon Song, Dalsan You, Cheryn Song, and Hanjong Ahn Sahyun PakSahyun Pak Seoul, Korea, Republic of More articles by this author , Sejun ParkSejun Park Seoul, Korea, Republic of More articles by this author , Sang Hoon SongSang Hoon Song Seoul, Korea, Republic of More articles by this author , Dalsan YouDalsan You Seoul, Korea, Republic of More articles by this author , Cheryn SongCheryn Song Seoul, Korea, Republic of More articles by this author , and Hanjong AhnHanjong Ahn Seoul, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.03.052AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In prostate-specific antigen(PSA) era, late detection of prostate cancer still exists when the tumor arised from anterior portion of prostate. We analyzed the characteristics of anterior predominant prostate cancer, and assess the usefulness of MRI to detect the tumor preoperatively. METHODS We evaluated clinicopathological data and radiologic findings of 660 patients treated with radical prostatectomy between July, 2007 and June, 2012. All patients underwent MRI with diffusion-weighted imaging, and ADC mapping. When the lesion was larger than 8mm in diameter, showed low signal intensity on T2-weighted image, restricted diffusion on diffusion-weighted images and ADC maps, it was considered presence of tumor. RESULTS Anterior predominant prostate cancer constituted 26.8% of total patients. Index tumor in anterior peripheral zone, anterior fibromuscular stroma, and transition zone were 27.7%, 3.4%, and 69.0% respectively. Age, BMI, PSA, prostate volume, and PSA density in anterior predominant prostate cancer were not different from posterior prostate cancer. Diagnosis with repeated biopsy was more frequent in anterior predominant cancer, and clinical T stage (p<0.001), pathologic T stage (p<0.001), pathologic GS (p=0.040) were lower. In D'Amico low-risk patients, anterior predominant cancer presented in 40.1%, and upgrading was more frequently observed than posterior predominant cancer (65.1% vs 49.5%, p=0.027). In anterior predominant cancer, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI were 64.2%, 83.0%, 63.8%, 83.2%, and 77.0%, respectively. CONCLUSIONS Anterior predominant cancer had favorable pathologic features compared with posterior dominant cancer. However, more frequent upgrading was noted. MRI was useful to detect the hidden anterior predominant cancer. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e548 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sahyun Pak Seoul, Korea, Republic of More articles by this author Sejun Park Seoul, Korea, Republic of More articles by this author Sang Hoon Song Seoul, Korea, Republic of More articles by this author Dalsan You Seoul, Korea, Republic of More articles by this author Cheryn Song Seoul, Korea, Republic of More articles by this author Hanjong Ahn Seoul, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Can transrectal needle biopsy be optimised to detect nearly all prostate cancer with a volume of ≥0.5 mL? A three‐dimensional analysis

To investigate whether transrectal needle biopsy can be optimised to detect nearly all prostate cancer with a tumour volume (TV) of ≥0.5 mL. Retrospectively analysed 109 whole-mounted and entirely submitted radical prostatectomy specimens with prostate cancer. All tumours in each prostate were outlined on whole-mount slides and digitally scanned to produce tumour maps. Tumour map images were exported to three-dimensional (3D) slicer software (http://www.slicer.org) to develop a 3D-prostate cancer model. In all, 20 transrectal biopsy schemes involving two to 40 cores and two to six anteriorly directed biopsy (ADBx) cores (including transition zone, TZ) were simulated, as well as models with various biopsy cutting lengths. Detection rates for tumours of different volumes were determined for the various biopsy simulation schemes. In 109 prostates, 800 tumours were detected, 90 with a TV of ≥0.5 mL (mean TV 0.24 mL). Detection rate for tumours with a TV of ≥0.5 mL plateaued at 77% (69/90) using a 12-core (3 × 4) scheme, standard 17-mm biopsy cutting length without ADBx cores. In all, 20 of 21 (95%) tumours with a TV of ≥0.5 mL not detected by this scheme originated in the anterior peripheral zone or TZ. Increasing the biopsy cutting length and depth/number of ADBx cores improved the detection rate for tumours with a TVof ≥0.5 mL in the 12-core scheme. Using a 22-mm cutting length and a 12-core scheme with additional volume-adjusted ADBx cores, 100% of ≥0.5 mL tumours in prostates ≤ 50 mL in volume and 94.7% of ≥0.5 mL tumours in prostates > 50 mL in volume were detected. Our 3D-prostate cancer model analysis suggests that nearly all prostate cancers with a TV of ≥0.5 mL can be detected by 14-18 transrectal needle-biopsy cores. Using longer biopsy cutting lengths and increasing the depth and number of ADBx cores (including TZ) according to prostate volume are necessary as well.

807 Characteristics of anterior predominant prostate cancer and the usefulness of multiparametric MRI in diagnosis

INTRODUCTION AND OBJECTIVES: In prostate-specific antigen(PSA) era, late detection of prostate cancer still exists when the tumor arised from anterior portion of prostate. We analyzed the characteristics of anterior predominant prostate cancer, and assess the usefulness of MRI to detect the tumor preoperatively. METHODS: We evaluated clinicopathological data and radiologic findings of 660 patients treated with radical prostatectomy between July, 2007 and June, 2012. All patients underwent MRI with diffusion-weighted imaging, and ADC mapping. When the lesion was larger than 8mm in diameter, showed low signal intensity on T2weighted image, restricted diffusion on diffusion-weighted images and ADC maps, it was considered presence of tumor. RESULTS: Anterior predominant prostate cancer constituted 26.8% of total patients. Index tumor in anterior peripheral zone, anterior fibromuscular stroma, and transition zone were 27.7%, 3.4%, and 69.0% respectively. Age, BMI, PSA, prostate volume, and PSA density in anterior predominant prostate cancer were not different from posterior prostate cancer. Diagnosis with repeated biopsy was more frequent in anterior predominant cancer, and clinical T stage (p 0.001), pathologic T stage (p 0.001), pathologic GS (p 0.040) were lower. In D’Amico low-risk patients, anterior predominant cancer presented in 40.1%, and upgrading was more frequently observed than posterior predominant cancer (65.1% vs 49.5%, p 0.027). In anterior predominant cancer, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI were 64.2%, 83.0%, 63.8%, 83.2%, and 77.0%, respectively. CONCLUSIONS: Anterior predominant cancer had favorable pathologic features compared with posterior dominant cancer. However, more frequent upgrading was noted. MRI was useful to detect the hidden anterior predominant cancer.

188 THE SUPERIORITY OF TRANSPERINEAL TEMPLATE MAPPING BIOPSY OF THE PROSTATE GLAND OVER THE TRANSRECTAL SATURATION APPROACH

You have accessJournal of UrologyProstate Cancer: Staging1 Apr 2011188 THE SUPERIORITY OF TRANSPERINEAL TEMPLATE MAPPING BIOPSY OF THE PROSTATE GLAND OVER THE TRANSRECTAL SATURATION APPROACH Stuart McCracken, Sarah Housley, Jose Dominguez-Escrig, Krishna Narahari, and Damian Greene Stuart McCrackenStuart McCracken Sunderland, United Kingdom More articles by this author , Sarah HousleySarah Housley Sunderland, United Kingdom More articles by this author , Jose Dominguez-EscrigJose Dominguez-Escrig Sunderland, United Kingdom More articles by this author , Krishna NarahariKrishna Narahari Sunderland, United Kingdom More articles by this author , and Damian GreeneDamian Greene Sunderland, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.258AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Attempts to maximise the effectiveness of repeat biopsy has given rise to the alternate approaches of saturation biopsy and the transperineal approach. Recent interest in focal treatment of prostate cancer has further highlighted the need for accurate detection of prostate cancer and in response, the introduction of transperineal template mapping biopsy (TTMB). In this study we aim to compare transrectal saturation and TTMB in men attending for repeat prostate biopsy. METHODS The study included 100 consecutive patients who required repeat biopsy based on rising PSA despite previous negative biopsy. The first 50 patients underwent transrectal saturation biopsies (mean age 65, range 52–77) and the second 50 patients underwent TTMB (mean age 62.9, range 37–75), utilizing a 5mm brachytherapy grid template. Median number of cores=18 (range 11–24) for transrectal saturation biopsy, median number of cores=44 (range 24–65) for TTMB. In the TTMB group, 10 patients opted for radical prostatectomy, allowing pathological comparisons of biopsy specimens and step-sectioned radical prostatectomy specimens. RESULTS Prostate cancer was detected in 46% (23/50) of the 50 TTMB performed, compared with 22% (11/50) for transrectal saturation biopsy. Of the TTMB biopsies positive for cancer, 43% (10/23) were unilateral and therefore suitable for focal hemi-cryotherapy. Of the TTMB biopsies positive for cancer 26% (6/23) had apical cancer alone, a zone at risk of inadequate sampling with the traditional transrectal route. Good correlation was seen between both groups with 1 out of 10 patients (10%) upgraded from unilateral to bilateral adenocarcinoma on radical prostatectomy histology. TTMB had a complication rate of 12% (5 patients with acute retention of urine, 1 hematuria requiring admission) compared with a complication rate of 22% for the transrectal saturation biopsy group (4 patients with UTI, 1 acute retention of urine, 2 hematuria requiring admission). CONCLUSIONS TTMB has a similar morbidity to transrectal saturation technique. Our study demonstrates that cancer detection rate is higher in patients who undergo TTMB (46% Vs 22%). Detection rate may be higher in TTMB due to better apical and anterior peripheral zone sampling. Despite the requirement for general anaesthesia and a potential increased urinary retention rate, novel transperineal mapping schemes allow for more accurate sampling of the entire gland. The remit of prostate biopsy now lies beyond pure diagnostics and has become an essential tool for determining optimal therapeutic approach. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e78 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stuart McCracken Sunderland, United Kingdom More articles by this author Sarah Housley Sunderland, United Kingdom More articles by this author Jose Dominguez-Escrig Sunderland, United Kingdom More articles by this author Krishna Narahari Sunderland, United Kingdom More articles by this author Damian Greene Sunderland, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Do prostatic transition zone tumors have a distinct morphology?

Previous studies have proposed that the morphologic spectrum of prostatic glands of variable size with tall columnar cells displaying basally oriented nuclei and clear to pale pink cytoplasm (TZ-LOOK) is characteristic of the well to moderately differentiated component of transition zone (TZ) tumors. However, the specificity of these findings has not been well studied. In a recent report, we identified dominant peripheral zone (PZ) and TZ tumors situated anterior to the prostatic urethra. Currently, we evaluate the histopathologic features of 215 dominant tumors, including 63 TZ and 73 anterior PZ lesions and an additional cohort of 79 posterior PZ tumors, in radical prostatectomy specimens, to identify the prevalence of this morphology in tumors of different zonal origin. Each dominant tumor was assigned a TZ-LOOK extent score of 0 to 4, with 0 = no such morphology, 1 = 1% to 25%, 2 = 26% to 50%, 3 = 51% to 75%, and 4 = >75%. Overall, 121/215 (56%) tumors showed some degree of this histology, including 56 of 63 (89%) TZ tumors and 65 of 152 (43%) PZ tumors (P<0.0001). Thirty-seven of 215 (17%) lesions had scores of 3 to 4, with 31 (84%) of these being of TZ origin. However, only 31/63 (49%) TZ tumors had >50% TZ-LOOK. Among PZ tumors, 6/152 (4%) had predominant (>50%) TZ-LOOK morphology, yet 23/152 (15%) of all PZ tumors and 23/65 (35%) of PZ tumors displaying any degree of TZ-LOOK had scores of 2 to 3 (>25%; nonfocal). In tumors of both zones with predominant (scores 3 to 4; >50%) TZ-LOOK histology, darker glands of usual acinar adenocarcinoma was often seen at the periphery. Conversely, in tumors with nonpredominant TZ-LOOK (scores 1 to 2; <or=50%), these glands were frequently admixed with small glands bearing dark cytoplasm. In this series, we demonstrate that some degree of TZ-LOOK morphology is twice as frequent in dominant TZ tumors than in PZ tumors. Tumors demonstrating >50% of this histology are very likely of TZ origin, but this scenario occurs in only half of TZ tumors. Importantly, the TZ-LOOK is nonfocal in up to 35% of PZ tumors exhibiting any degree of this morphology. Given this lack of specificity, caution should be exercised in assigning zone of origin based on this histologic appearance, especially in limited samples such as prostate needle biopsy.

Anterior apical biopsy: Is it useful for prostate cancer detection?

To evaluate the utility of a 12-core prostate biopsy protocol including apical anterior peripheral zone (AAPZ) cores. Between February 2002 and October 2006, 10-core and 12-core initial transrectal prostate biopsies were performed on 164 and 549 men, respectively. Two AAPZ-directed biopsies were included in the 12-core biopsy. During the same period, 12-core repeat biopsies including six AAPZ sites were performed on 118 men. Cancer was found in 66 cases (40.2%) in the 10-core biopsy group and in 252 (45.9%) in the 12-core biopsy group. In this latter group, 13 (5.2%) of the 252 men with positive biopsy had cancer exclusively in the AAPZ cores. When the cancer detection rate at initial biopsy in AAPZ alone was compared according to the digital rectal examination (DRE) findings, it was significantly higher in men with normal rather than abnormal DRE: 12/250 (3.4%) vs 1/185 (0.5%) (P < 0.01). In repeat 12-core biopsies, cancer was detected in 25 (21.2%) men and 9 of them (36.0%) had cancer exclusively in the AAPZ cores. The cancer detection rate from AAPZ sites was significantly higher in repeat biopsy than that in initial biopsy (P < 0.01). Addition of the AAPZ site-directed biopsy had greater utility in men with normal DRE and particularly in patients with a prior negative biopsy.

Editorial Comment

The search for the optimal biopsy strategy continues. An increasing number of lateral biopsies in addition to traditional sextant biopsy, saturation biopsy, the selection of computer-based sampling sites,1, 2 image-guided directed biopsy (using emerging imaging technology with magnetic resonance imaging and/or transrectal ultrasonography), the indication of repeat biopsy and so on are all under investigation. To identify the biopsy strategy without missing clinically significant cancer with a minimum number of biopsies taken is a true challenge. Orikasa et al. should be congratulated on their pioneering work in proving a clinically significant sampling site. This article addresses the clinical utility of an apical anterior peripheral zone biopsy in men with normal digital rectal examination (DRE), and particularly in men with a prior negative biopsy.3 As reinforced by this article, repeat biopsy, indicated by continuously elevated prostate-specific antigen with normal DRE, needs site-directed biopsies from the areas where the previous biopsies have not been taken. After the landmark work of computer-based sampling analysis by Chen et al.1 to target the anterior horn peripheral zone, the apical anterior peripheral zone could become another significant sampling site, as this article and Matsumoto et al. point out.2 The importance is not only in an improved detection rate. Since the positive surgical margin most likely occurs in an apical dissection,4 pre-operative cancer mapping provided by a positive biopsy outcome in this site will contribute to better oncologic therapeutic outcomes.

Anterior-predominant Prostatic Tumors: Zone of Origin and Pathologic Outcomes at Radical Prostatectomy

Aggressive screening and prostate needle biopsy protocols have been successful in early detection of low-volume posterior tumors. Consequently, we have observed an increased incidence of anterior-predominant prostate cancers. However, the zones of origin, patterns of spread, and patterns of extraprostatic extension of this group of tumors have not been well studied. Of 1312 radical prostatectomies performed at our institution over a span of 4.5 years, 197 had predominant (largest) tumors anterior to the urethra in whole-mounted radical prostatectomy specimens. Detailed histopathologic analysis of this cohort was undertaken emphasizing the variability in anterior prostatic anatomy from apex through base to determine zone of origin and pathologic staging. Using this approach, 97/197 (49.2%) anterior-predominant tumors (ATs) were assigned to the anterior peripheral zone (APZ), 70 (35.5%) to the transition zone (TZ), 16 (8.1%) were of indeterminate zone, and 14 (7.1%) were of both zones. Comparing APZ and TZ tumors, there were no significant differences in Gleason scores, incidence of extraprostatic extension, overall surgical margin positivity rate, or laterality. Involvement of the anterior fibromuscular stroma was significantly more likely in tumors of TZ origin (P< or =0.01), yet was observed in 50.5% of APZ tumors. Conversely, APZ tumors were more commonly localized within the apical one third of the prostate. Most of the prostates (91.4%) also showed additional PZ tumors, which were occasionally stage determining (7/197; 3.9%). In conclusion, ATs of APZ origin are more prevalent than those arising from the TZ. Contrary to previous reports comparing TZ tumors to all PZ tumors, ATs of both zones exhibit similar grading and staging parameters in this series. Given these similarities, long-term clinical outcomes and future molecular analyses will be necessary to assess whether true differences in biology and behavior exist between tumors of TZ and APZ origin.

Transitional Zone and Anterior Peripheral Zone of the Prostate

Introduction: Prognostically significant prostatic adenocarcinomas (PAC) may pose diagnostic problems if they were localized in the anterior peripheral zone (APZ) or transitional zone (TZ). Materials and Methods: 108 cases of PAC were reviewed along with serum PSA and TRUS biopsies. The PACs were divided into 22 TZ, 17 APZ and 69 posterior peripheral zone (PPZ) PACs according to the location of the main tumor mass in the TZ and anterior or posterior half of the peripheral zone in the radical prostatectomy (RP) specimens. Results: In comparison with PPZ PAC, TZ PAC had a higher cancer volume in RP specimens (4 ± 2.1 vs. 2.5 ± 1.7 cm³, p < 0.01), a higher serum PSA (16.5 ± 9.8 vs. 8.4 ± 4.5 µg/l, p < 0.001), a biopsy with a small cancer volume (3.8 ± 2.1 vs. 11.8 ± 9.4 mm, p < 0.005), and a lower Gleason’s score (4.8 ± 2.1 vs. 6.5 ± 1.7). APZ PAC was characterized by the cancer volume in RP and biopsy and PSA intermediate between those of TZ and PPZ PAC. Among 24 PACs with a total cancer core length of <3 mm, 19 cases were from the TZ and APZ groups and also had a higher cancer volume and PSA than those from the PPZ group (2.9 ± 1.8 vs. 1.5 ± 1.3 and 13.7 ± 8.3 vs. 9.6 ± 4 µg/l, respectively). Furthermore, there was a better correlation coefficient (r²) of tumor volume in the biopsy and RP for PPZ than for all zones PAC (r² = 0.75 vs. 0.29). TZ and APZ carcinomas were associated with extension or satellite nodules of PAC in the PPZ that may be diagnosed with biopsies. These PACs were associated with positive anterior resection margin due to extracapsular extension of the carcinoma or intracapsular dissection in 6 and 5 cases respectively. Conclusions: TZ and APZ PACs accounted for the poor correlation between the tumor volume in the biopsy and the RP, and were associated with positive anterior resection margins. One core biopsy with a total cancer core length of <3 mm and PSA >10 µg/l are suspicious for TZ and APZ PCA in patients with undetectable tumors with DRE or TRUS. Clinically insignificant PACs tend to be associated with cancer core <3 mm and PSA <10 µg/l.

Functional role of V form distribution seen in microvascular cast specimens of the filiform and fungiform papillae on the posterior central dorsal surface of the cat tongue

The relationship between the functional role and three-dimensional structures of the microvascular network of the filiform papillae (FiP) and fungiform papillae (FuP) on the posterior central surface of the cat tongue were observed by the corrosion cast method under a scanning electron microscope (SEM). FiP can be classified into five types; types I-V (Ojima and Lowe 1995), and FuP, found to be distributed sporadically among FiP (I-V), into four types; types I-IV (Ojima et al. 1996 b) according to the shape and size of the main process (MP) and the number of the accessory processes (AP). Each of the types I-V of FiP were arranged in the form of a V as oblique lines running in an orderly and geometrical fashion from the posterior central zone to the anterior peripheral zone in both directions. Each of the types I-IV of FuP were scattered throughout the line of FiPs arranged in the form of a V, the point of which is directed towards the pharynx. FiPs play an important role in the drinking of milk and water, holding, masticating and swallowing the food and, after mixing the food with saliva, in the transporting of the food mass towards the pharynx. The MP of FuPs is considered to be a modified form of the MP of FiP of the cat tongue function (Ojima et al. 1996 c) as part of a sense organ for taste.