Biopsy Strategy Research Articles

Avoiding Unnecessary Magnetic Resonance Imaging (MRI) and Biopsies: Negative and Positive Predictive Value of MRI According to Prostate-specific Antigen Density, 4Kscore and Risk Calculators

The 2019 European Association of Urology guidelines recommend multiparametric magnetic resonance imaging (mpMRI) for biopsy-naïve patients with clinical suspicion of prostate cancer (PC) and avoiding biopsy in patients with negative mpMRI and low clinical suspicion. However, consensus on the optimal definition of low clinical suspicion is lacking. We evaluated 266 biopsy-naïve patients who underwent mpMRI, the 4Kscore test, and prostate biopsy to define the best strategy to avoid unnecessary testing and biopsies. The European Randomized Study of Screening for Prostate Cancer risk calculator (ERSPC-RC) and prostate-specific antigen density (PSAd) were also considered. For men with Prostate Imaging-Reporting and Data System v2.0 (PI-RADS) 1⿿2 lesions, the highest negative predictive value was observed for those with low or intermediate 4Kscore risk (96.9% and 97.1%), PSAd <0.10ng/ml/cm3 (98.7%), and ERSPC-RC <2% (98.7%). For men with PI-RADS 3⿿5 lesions the lowest positive predictive value was observed for those with low 4Kscore risk (0%), PSAd <0.10ng/ml/cm3 (13.2%), and ERSPC-RC <2% (12.3%). The best biopsy strategy was an initial 4Kscore followed by mpMRI if the 4Kscore was>7.5% and a subsequent biopsy if the mpMRI was positive (PI-RADS 3⿿5) or the 4Kscore was ⿥18%. This would result in missing 2.7% (2/74) of clinically significant PCs (csPCs) and avoiding 34.2% of biopsies. Initial mpMRI followed by biopsy for negative mpMRI (PI-RADS 1⿿2) if the 4Kscore was ⿥18% or PSAd was ⿥0.10ng/ml/cm3 resulted in a similar percentage of csPC missed (2.7% [2/74] and 1.3% [1/74]) but slightly fewer biopsies avoided (25.2% and 28.1%). Physicians should consider clinical risk screening tools when ordering and interpreting mpMRI results to avoid unnecessary testing and diagnostic errors. Patient summaryPerforming the 4Kscore test in conjunction with multiparametric magnetic resonance imaging for men with a clinical suspicion of prostate cancer may help to reduce unnecessary biopsies.

Prebiopsy IMPROD Biparametric Magnetic Resonance Imaging Combined with Prostate-Specific Antigen Density in the Diagnosis of Prostate Cancer: An External Validation Study

BackgroundBiparametric magnetic resonance imaging (bpMRI) combined with prostate-specific antigen density (PSAd) may be an effective strategy for selecting men for prostate biopsy. It has been shown that performing biopsy only for men with bpMRI Likert scores of 4–5 or PSAd ≥0.15 ng/ml/cm3 is the most efficient strategy. ObjectiveTo externally validate previously published biopsy strategies using two prospective bpMRI trial cohorts. Design, setting, and participantsAfter IMPROD bpMRI, 499 men had systematic transrectal prostate biopsies and men with IMPROD bpMRI Likert scores of 3–5 had an additional two to four targeted biopsies. Outcome measurements and statistical analysisVarious IMPROD bpMRI Likert score and PSAd thresholds were assessed using detection rates for significant prostate cancer (sPCa; Gleason score ≥3 + 4), predictive values, and proportion of biopsies avoided. Net benefits and decision curve analyses (DCA) were compared with the aim of finding an optimal strategy for sPCa detection. Combined biopsies were used for reference. Results and limitationsThe negative predictive value (NPV) for sPCa in IMPROD bpMRI Likert 3–5 and 4–5 score groups was 93% and 92%, respectively, while the corresponding positive predictive value (PPV) was 57% and 72%, respectively. In DCA, the optimal combination was IMPROD bpMRI Likert score 4–5 or Likert 3 with PSAd ≥0.20 ng/ml/cm3, which had NPV of 93% and PPV of 67%. Using this combination, 35% of the study patients would have avoided biopsies and 13 sPCas (6%, 13/229, of all sPCas diagnosed) would have been missed. ConclusionsIMPROD bpMRI demonstrated a good NPV for sPCa. PSAd improved the NPV mainly among men with equivocal suspicion on IMPROD bpMRI. However, the additional value of PSAd was marginal: the NPV and PPV for IMPROD bpMRI Likert 4–5 score group were 92% and 72%, respectively, while the corresponding values for the best combination strategy were 93% and 67%. Patient summaryWe investigated a rapid prostate magnetic resonance imaging protocol (IMPROD bpMRI) combined with prostate-specific antigen (PSA) density for detection of significant prostate cancer. Our results show that IMPROD bpMRI is a good diagnostic tool, but the additional value provided by PSA density is marginal.

Accuracy of endoscopic staging and targeted biopsies for routine gastric intestinal metaplasia and gastric atrophy evaluation study protocol of a prospective, cohort study: the estimate study

IntroductionPatients with chronic atrophic gastritis (CAG) and intestinal metaplasia (IM) are at risk of developing gastric adenocarcinoma. Their diagnosis and management currently rely on histopathological guidance after random endoscopic biopsy...

The Specific Choice of Transrectal Ultrasound-Guided Prostate Biopsy Scheme Based on Prostate Specific Antigen and Prostate Specific Antigen Density.

BackgroundAlthough magnetic resonance imaging (MRI)-targeted biopsy and saturation biopsy can improve the accuracy of prostate biopsy, transrectal ultrasound (TRUS)-guided prostate biopsy is still the cornerstone for diagnosis of prostate cancer. However, it is not clear whether it is necessary to perform the same TRUS-guided biopsy scheme for patients with different prostate specific antigen (PSA) or prostate specific antigen density (PSAD) levels. The purpose of this study was to evaluate the optimal core number for specific suspected prostate cancer patients.Material/MethodsThere were 398 patients who underwent 12-core biopsy scheme, who were included in this retrospective analysis. The 12-core scheme incorporated a classic sextant scheme and 4-core biopsies from the base and middle regions bilaterally. The cancer detection rates of patients with different PSA or PSAD levels between the 12-core, sextant, 4-core, and 2-core biopsy were compared.ResultsThe differences in cancer detection rates between the 12-core biopsy scheme and the sextant biopsy scheme were significant in patients with PSA <20 ng/mL or PSAD <0.3. There were no differences in the cancer detection rates between the 12-core biopsy scheme and the 4-core biopsy scheme in patients with PSA ≤50 ng/mL or PSAD ≤1.0. There were significant differences between 12-core and 2-core scheme when PSA ≤70 ng/mL or PSAD ≤1.5.ConclusionsWe recommend that the 12-core biopsy should be used for patients with PSA <20 ng/mL or PSAD <0.3. The biopsy scheme in patients with PSA 20–50 ng/mL or PSAD 0.3–1.0 should be considered in combination with DRE and MRI. For patients with PSA >50 ng/mL or PSAD >1.0, we recommend 6-core or 4-core biopsy by comprehensively considering multiple factors. The 2-core biopsy is recommended for patients with PSA >70 ng/mL or PSAD >1.5.

Potential role of autofluorescence imaging in determining biopsy of oral potentially malignant disorders: A large prospective diagnostic study

Autofluorescence examination of oral tissues using the VELscope has been suggested as an adjunctive tool for cancer detection and diagnosis. This study aimed to determine the diagnostic value of VELscope in a large prospective study of 517 patients with oral potentially malignant disorders (OPMD). For the outcome assessments of discrimination of carcinoma form general OPMD and distinguishing high-risk lesions (moderate/severe dysplasia and carcinoma) from low-risk lesions (no/mild dysplasia), high sensitivity (100% and 95.9% respectively) and negative predictive value (100% and 98.2% respectively) were observed. All the carcinoma and showed loss of autofluorescence (LAF) and only 3 (0.6%) moderate/severe dysplasia were observed without LAF.These data indicate that the cases without LAF using VELscope substantially rule out the presence of high-risk lesions including cancer. This may prove to be useful specially to alleviate patient anxiety regarding a clinically suspicious oral lesion without the LAF, and to avoid a unnecessary biopsy for these cases. Collectively, a perspective to highlight was that a no biopsy strategy may be appropriate for OPMD without LAF using VELscope after conventional oral examination.

Developing an effective strategy to improve the detection of significant prostate cancer by combining the 4Kscore and multiparametric MRI

ObjectivesRecent years have seen the development of biomarkers and imaging technologies designed to improve the specificity of PSA. Widespread implementation of imaging technologies, such as mp-MRI raises considerable logistical challenges. Our objective was to evaluate a biopsy strategy that utilizes selective mp-MRI as a follow-up test to biomarkers to improve the detection of significant prostate cancer. Methods and MaterialsWe developed a conceptual approach based on the risk calculated from the 4Kscore using results from the US prospective validation study, multiplied by the likelihood ratio of mp-MRI from the PROMIS trial. The primary outcome was Gleason grade ≥ 7 (grade group ≥ 2) cancer on biopsy. Using decision curve analysis, the net benefit was determined for our model and compared with the use of the 4Kscore and mp-MRI independently at various thresholds for biopsy. ResultsFor a cut-point of 7.5% risk of high-grade disease, patients with <5% risk from a blood marker would not have risk of significant prostate cancer sufficiently increased by a positive mp-MRI to warrant biopsy; comparably, patients with a risk >23% would not have risk sufficiently reduced by a negative imaging study to forgo biopsy. From the 4Kscore validation study, 46% of men considered for biopsy in the US have risks 5% to 23%. Net benefit was highest for the combined strategy, followed by 4Kscore alone. ConclusionsSelective mp-MRI in men with intermediate scores on a secondary blood test results in a biopsy strategy that is more scalable than mp-MRI for all men with elevated PSA. Prospective validation is required to demonstrate if the predicted properties of combined blood and imaging testing are empirically confirmed.

Systematic prostate biopsy still matters: A comprehensive analysis of MRI/TRUS-fusion targeted prostate biopsies across different indications

ObjectivesTo assess if a multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy (TB) strategy is precise enough to replace systematic biopsies (SB) among men with different biopsy indications since an imaging-based pathway to guide indication and targeted prostate biopsy is currently under debate. Materials and MethodsRetrospective analysis was performed of 594 patients with one or more lesions according to Prostate Imaging and Reporting Data System (PI-RADS) receiving a consecutive TB and SB for one of the 3 indications: primary cancer suspicion (51.7%), persistent cancer suspicion after prior negative biopsy (35.4%), or control of a confirmed cancer (12.9%). Detection rates for overall cancer (CaP) and clinically significant cancer (csCaP, Gleason Score ≥3+4) were compared between TB and SB and to a combined approach for all patients and within the subgroups. Characteristics of cancers missed by one biopsy strategy were analyzed. ResultsTB detected less CaP (302 vs. 366, P < 0.001) and csCaP (204 vs. 210 patients, P = 0.409) compared to SB except for men with prior negative biopsies (65 vs. 64 csCaP, P = 0.363). Cancer detection by TB or SB was independent of cancer localization and imaging characteristics. Combined TB and SB outperformed the single approaches for CaP and csCaP detection in each subgroup. ConclusionsA single mpMRI and TB approach leads to a substantial number of missed CaP and csCaP across biopsies with different indications. Ongoing improvements of imaging, reading standardization, and biopsy techniques are required before replacing SB.

Prospective Study of the Utility of Computed Tomography Triage of Pleural Biopsy Strategies in Patients With Pleural Diseases.

This study aimed to prospectively evaluate the efficacy and reliability of a diagnostic workup, triaging pleural biopsy method according to baseline computerized tomography (CT) findings in the diagnosis of pleural diseases. Patients with pleural pathology were divided into 3 arms according to findings on CT scan images. Arm A: patients with pleural thickening/lesion in addition to pleural effusion. These patients underwent CT scan-guided Abrams' needle pleural biopsy. Arm B: patients with pleural effusion alone or suspected benign asbestos pleurisy. This group underwent medical thoracoscopy (MT). Arm C: patients with only pleural thickening. This group underwent ultrasonography-guided cutting needle pleural biopsy. MT was planned in patients who did not have a specific diagnosis in the CT scan-guided Abrams' needle pleural biopsy group. When patients with a histopathologic diagnosis of fibrinous pleuritis after MT were assessed in terms of the risk factors for malignant pleural diseases, we offered a further invasive procedure. A total of 164 patients were enrolled in the study. Diagnostic sensitivity after the initial procedure was 90.2% in Arm A, 93.3% in Arm B, 95.2% in Arm C, and 92.4% in the entire workup. The negative predictive value of the entire workup was 90.4% for malignant pleural mesothelioma, 97.1% for metastatic malignant pleural diseases, and 100% for tuberculous pleurisy. Five cases who had a diagnosis of fibrinous pleuritis after MT were detected to have risk factors, 4 of which (80%) indicated malignant disease. Complication rates were low and acceptable. Use of CT scans to triage an appropriate pleural biopsy method is associated with high diagnostic success. We recommend that the proposed diagnostic workup in this study may be used as a diagnostic algorithm for pleural diseases that require a histopathologic analysis. Determination of risk factors predicting malignant disease in patients where fibrinous pleuritis is reported after MT would be useful for clinical practice.

Added Value of Concomitant Systematic and Fusion Targeted Biopsies for Grade Group Prediction Based on Radical Prostatectomy Final Pathology on Positive Magnetic Resonance Imaging.

We assessed the added value of concomitant systematic biopsy for final grade group prediction in patients with positive magnetic resonance imaging who were undergoing targeted biopsy. Included in study were 478 consecutive patients with prebiopsy positive multiparametric magnetic resonance imaging and a greater than 10-core systematic biopsy combined with fusion targeted biopsy who underwent radical prostatectomy. The primary end point was the grade group concordance between biopsy and radical prostatectomy pathology according to the biopsy technique. Clinical and biological factors associated with the performance of systematic biopsy were analyzed. Adding systematic biopsy to targeted biopsy modified the d'Amico risk classification toward more intermediate and high risk in 7.8% of cases, mainly from low to intermediate risk with low risk prostate cancer on targeted biopsy in 44.3%. This reclassification was significantly higher in patients with lower prostate specific antigen and with prostate specific antigen density less than 0.20 ng/ml/gm (11.7% vs 2.4%, p <0.001). The concordance rate between biopsy pathology and radical prostatectomy pathology significantly differed between targeted biopsy and targeted biopsy plus systematic biopsy (45.2% and 51.7%, respectively). The upgrading rate in radical prostatectomy specimens decreased by 22% when systematic biopsy was added to targeted biopsy. Patients in whom systematic biopsy did not modify grading were more likely to have pT3-4 and/or pN1 disease on final pathology (56.9% vs 38.3%, p=0.007). Grading concordance between biopsy pathology and radical prostatectomy pathology was improved by adding systematic biopsy in all patient subgroups. Patients with prostate specific antigen density less than 0.20 ng/ml/gm benefited the most from this combined biopsy strategy. Systematic biopsy reclassified a nonnegligible number of cases toward a higher risk category, mainly the low risk cases. Thus, systematic biopsy could modify treatment decision making.

Performance of systematic, MRI-targeted biopsies alone or in combination for the prediction of unfavourable disease in MRI-positive low-risk prostate cancer patients eligible for active surveillance.

To assess the upstaging/upgrading rates of low-risk prostate cancer (PCa) according to the biopsy scheme used (systematic (SB), targeted biopsies (TB), or both) in the setting of positive pre-biopsy MRI. We included 143 consecutive men fulfilling the Toronto University active surveillance (AS) criteria who underwent a pre-biopsy positive MRI, a combination of SB and software-based fusion TB, and a radical prostatectomy, in two expert centres. The primary endpoints were the pathological upgrading and upstaging rates. Overall unfavourable disease (OUD) was defined by any pT3-4 and/or pN1 and/or ≥ GG 3. Using TB alone would have missed 21.7% of cancers including 16.7% of ≥ GG 3. The use of TB was significantly associated with a lower risk of ≥ Grade Group (GG) 3 disease (p < 0.006) in RP specimens. Combination of SB and TB lowered this risk by 39%, compared with TB alone. The biopsy scheme did not affect the upstaging rates which were substantial even in case of combination scheme (from 37 to 46%). OUD was detected in approximately 50% of cases. The presence of high grade on TB was the only independent predictive factor for both ≥ GG 2 (p = 0.015) and ≥ GG 3 (p = 0.023) in RP specimens. High grade on TB biopsies represented the major predictor of upgrading. Combination of SB and TB better defined the sub-group of patients having the lowest risk of reclassification, compared with TB or SB alone. The risk of non-organ-confined disease remained high, and could not be accurately predicted by MRI or systematic/targeted biopsy features.

Biologic Significance of Magnetic Resonance Imaging Invisibility in Localized Prostate Cancer.

Multiparametric magnetic resonance imaging (mpMRI) is used widely for prostate cancer (PCa) evaluation. Approximately 35% of aggressive tumors, however, are not visible on mpMRI. We sought to identify the molecular alterations associated with mpMRI-invisible tumors and determine whether mpMRI visibility is associated with PCa prognosis. Discovery and validation cohorts included patients who underwent mpMRI before radical prostatectomy and were found to harbor both mpMRI-visible (Prostate Imaging and Reporting Data System 3 to 5) and -invisible (Prostate Imaging and Reporting Data System 1 or 2) foci on surgical pathology. Next-generation sequencing was performed to determine differential gene expression between mpMRI-visible and -invisible foci. A genetic signature for tumor mpMRI visibility was derived in the discovery cohort and assessed in an independent validation cohort. Its association with long-term oncologic outcomes was evaluated in a separate testing cohort. The discovery cohort included 10 patients with 26 distinct PCa foci on surgical pathology, of which 12 (46%) were visible and 14 (54%) were invisible on preoperative mpMRI. Next-generation sequencing detected prioritized genetic mutations in 14 (54%) tumor foci (n = 8 mpMRI visible, n = 6 mpMRI invisible). A nine-gene signature (composed largely of cell organization/structure genes) associated with mpMRI visibility was derived (area under the curve = 0.89), and the signature predicted MRI visibility with 75% sensitivity and 100% specificity (area under the curve = 0.88) in the validation cohort. In the testing cohort (n = 375, median follow-up 8 years) there was no significant difference in biochemical recurrence, distant metastasis, or cancer-specific mortality in patients with predicted mpMRI-visible versus -invisible tumors (all P > .05). Compared with mpMRI-invisible disease, mpMRI-visible tumors are associated with underexpression of cellular organization genes. mpMRI visibility does not seem to be predictive of long-term cancer outcomes, highlighting the need for biopsy strategies that detect mpMRI-invisible tumors.

Anatomic location of Barrett’s esophagus recurrence after endoscopic eradication therapy: development of a simplified surveillance biopsy strategy

Surveillance endoscopy is recommended after endoscopic eradication therapy (EET) for Barrett's esophagus (BE) because of the risk of recurrence. Currently recommended biopsy protocols are based on expert opinion and consist of sampling visible lesions followed by random 4-quadrant biopsy sampling throughout the length of the original BE segment. Despite this protocol, some recurrences are not visibly identified. We aimed to identify the anatomic location and histology of recurrences after successful EET with the goal of developing a more efficient and evidence-based surveillance biopsy protocol. We performed an analysis of a large multicenter database of 443 patients who underwent EET and achieved complete eradication of intestinal metaplasia (CE-IM) from 2005 to 2015. The endoscopic location of recurrence relative to the squamocolumnar junction (SCJ), visible recurrence identified during surveillance endoscopy, and time to recurrence after CE-IM were assessed. Fifty patients with BE recurrence were studied in the final analysis. Seventeen patients (34%) had nonvisible recurrences. In this group, biopsy specimens demonstrating recurrence were taken from within 2 cm of the SCJ in 16 of these 17 patients (94%). Overall, 49 of 50 recurrences (98%) occurred either within 2 cm of the SCJ or at the site of a visible lesion. Late recurrences (>1 year) were more likely to be visible than early (<1 year) recurrences (P= .006). Recurrence after EET detected by random biopsy sampling is identified predominately in the distal esophagus and occurs earlier than visible recurrences. As such, we suggest a modified biopsy protocol with targeted sampling of visible lesions followed by random biopsy sampling within 2 cm of the SCJ to optimize detection of recurrence after EET. (Clinical trial registration number: NCT02634645.).

Comprehensive Chromosome screening using MALBAC-NGS with cleavage-state embryos as an option for treatment of patients with chromosomal disorders

Introduction Comprehensive chromosome screening with next generation sequencing (NGS) has been proved effective in detecting chromosomal abnormalities and has been successfully used in treating patients with chromosomal disorders. In most clinical practice, embryos were in-vitro cultured to blastocyst, trophectoderm biopsies were performed before embryos were cryopreserved for embryo transfer. However, patients with poor embryo number and quality often experienced tremendous stress with the limited blastocyst formation rate. Material & Methods In IVF center of Women's Hospital, Zhejiang University School of Medicine, from July 2016 to January 2018, we have performed preimplantation genetic diagnosis- aneuploidy (PGD-A) on 124 ICSI cycles using MALBAC-NGS with cleavage-state embryos for treatment of patients with chromosomal disorders. Results 61 cycles were performed with D3 biopsy and D4 fresh embryo transfer with overnight MALBAC-NGS reporting; and 63 cycles were performed with D3 biopsy using frozen-thawed embryos and we have seen no significant difference in both clinical pregnancy rate (CPR, 49.18% fresh vs 46.03% frozen) and ongoing pregnancy rate (OPR, 44.26% fresh vs 44.44% frozen). PGD-A also shows significantly improved CPR and OPR versus matched single embryo transfer (SET) cycles as well as FISH-PGD. Conclusions D3 biopsy and D4 fresh embryo transfer strategy in our center is a viable option, especially in patients having concerns about blastocyst culture and frozen embryo transfer with low OHSS risk.

MP18-12 OPTIMAL BIOPSY STRATEGY FOR PROSTATE CANCER DETECTION BY PERFORMING A BAYESIAN NETWORK META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

INTRODUCTION AND OBJECTIVES:With the increasing recognition of the over-diagnosis and over-treatment of prostate cancer (PCa), the choice of a better prostate biopsy strategy had confused both the ...

Use of multiparametric magnetic resonance imaging in prostate cancer active surveillance.

To review the role of multiparametric magnetic resonance imaging (mpMRI) for active surveillance (AS) of prostate cancer. We performed a comprehensive search of Medline and Embase databases for relevant articles in the English language. Search terms included 'prostate cancer', 'active surveillance' or 'monitoring', 'expectant management', and 'MRI'. We also reviewed practice guidelines from recognized international associations or societies involved in prostate cancer care. Articles were selected by both authors for relevance to the subject matter. The ability of mpMRI to visualize primarily high-grade tumours within the prostate may improve risk stratification for men considering AS for prostate cancer. Multiple mostly single-institution studies have found that the addition of mpMRI and a targeted biopsy strategy can improve AS patient selection over standard TRUS biopsy alone. The high negative predictive value of mpMRI may allow men to avoid early repeat biopsy and may offer the possibility to tailor biopsy strategies. The presence of a radiographically positive lesion on mpMRI at baseline is predictive of higher likelihood of radiographic progression over time while on AS. MRI has shown promise in both patient selection and monitoring for men who undergo AS for prostate cancer. There are multiple barriers to the widespread use of mpMRI for AS including quality, cost and access to care.

Percutaneous endovascular tissue sampling of endoluminal tumors using directional atherectomy.

To evaluate technical feasibility and safety of endovascular tumor specimen sampling using an escalating endovascular biopsy strategy using a directional atherectomy device compared with forceps biopsy and catheter aspiration. Between 2013 and 2017, a cohort of ten consecutive patients (6 male; median age 56, range 39-73years) was referred for sampling of endovascular masses. Localizations included the abdominal aorta (n = 4), left brachiocephalic vein (n = 2), inferior vena cava (n = 1), and left pulmonary artery (n = 3). For each individual mass, all three endovascular tissue sampling approaches were applied including catheter-based aspiration, straight two-jaw biopsy forceps, and directional atherectomy during a single session. Aspiration and forceps biopsy did not provide sufficient material for histological analyses. In contrast, technical success for endovascular tumor sampling using directional atherectomy was 100%. After two atherectomy passages, sufficient material was available for each vessel region allowing histologic diagnosis, which revealed sarcoma and chronic inflammation for masses in the aorta, angiosarcoma for brachiocephalic vein, hepatocellular carcinoma for inferior vena cava, and angiosarcoma for pulmonary artery. In case of a histologically benign diagnosis, no malignant tumor proliferation was obvious on follow-up imaging studies after 3months and 1year. Thus, the rate of false-negative results was considered 0%. No procedure-associated complications, e.g., vessel perforation, were recorded. Preliminary results in a limited number of patients proved directional atherectomy beneficial as a safe and feasible technique for endoluminal tissue sampling of vascular masses. Additional large-scale studies are necessary and worthy for further evaluation in clinical practice. • Endovascular masses pose a challenge to appropriate clinical management. • Off-label directional atherectomy proved to be a safe and feasible technique for endoluminal tissue sampling of vascular masses. Furthermore, directional atherectomy was superior to aspiration or forceps biopsy in our small study cohort. • Directional atherectomy may represent the last or only option for tissue probing as a prerequisite for further treatment decisions.

A prospective analysis of robotic targeted MRI-US fusion prostate biopsy using the centroid targeting approach

Robotic prostate biopsy is an emerging technology. Recent development of this tool has allowed the performance of a transperineal prostate biopsy allowing pre-programmed standardized biopsy schemes. Prospective data collection was undertaken in 86 consecutive men who underwent robotically assisted transperineal prostate biopsy. All underwent a multi-parametric MRI pre-biopsy with centroid targeting followed by systematic template prostate biopsy. For the purposes of this study, our definition of clinically significant prostate cancer (csPCa) is any Gleason score > 6. Mean (SD) age, median (IQR) PSA, and median (IQR) prostate volume were 64.24 (6.97) years, of 7.79 ng/ml (6.5) and 45.06 cc (28), respectively. Overall, 44 (51.2%) men were diagnosed with csPCa. csPCa was detected in the targeted biopsies alone in 35 (40.1%) men. The addition of the 12-zone template biopsy increased the yield of csPCa for another 9 (10.5%) men. Of these 9 men, the majority (7) harbored primary pattern 3 disease and only 1 was identified to have high-grade disease. Out of these 9 men, 7 of them had the identification of csPCa in the sector, where a target was contained within that zone. Robotic-assisted prostate biopsy in our study has demonstrated a high detection of csPCa when combined with limited near-field sampling. Our study suggests the use of more accurate biopsy schemes such as ring-targeting of lesions to mitigate against systematic and random mathematical errors. Adoption of this tool and biopsy strategy would potentially avoid the increased morbidity associated with whole gland systematic unguided biopsies.

Population net benefit of prostate MRI with high spatiotemporal resolution contrast-enhanced imaging: A decision curve analysis.

The value of dynamic contrast-enhanced (DCE) sequences in prostate MRI compared with noncontrast MRI is controversial. To evaluate the population net benefit of risk stratification using DCE-MRI for detection of high-grade prostate cancer (HGPCA), with or without high spatiotemporal resolution DCE imaging. Decision curve analysis. Previously published patient studies on MRI for HGPCA detection, one using DCE with golden-angle radial sparse parallel (GRASP) images and the other using standard DCE-MRI. GRASP or standard DCE-MRI at 3 T. Each study reported the proportion of lesions with HGPCA in each Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) category (1-5), before and after reclassification of peripheral zone lesions from PI-RADS 3-4 based on contrast-enhanced images. This additional risk stratifying information was translated to population net benefit, when biopsy was hypothetically performed for: all lesions, no lesions, PI-RADS ≥3 (using NC-MRI), and PI-RADS ≥4 on DCE. Decision curve analysis was performed for both GRASP and standard DCE-MRI data, translating the avoidance of unnecessary biopsies and detection of HGPCA to population net benefit. We standardized net benefit values for HGPCA prevalence and graphically summarized the comparative net benefit of biopsy strategies. For a clinically relevant range of risk thresholds for HGPCA (>11%), GRASP DCE-MRI with biopsy of PI-RADS ≥4 lesions provided the highest net benefit, while biopsy of PI-RADS ≥3 lesions provided highest net benefit at low personal risk thresholds (2-11%). In the same range of risk thresholds using standard DCE-MRI, the optimal strategy was biopsy for all lesions (0-15% risk threshold) or PI-RADS ≥3 on NC-MRI (16-33% risk threshold). GRASP DCE-MRI may potentially enable biopsy of PI-RADS ≥4 lesions, providing relatively preserved detection of HGPCA and avoidance of unnecessary biopsies compared with biopsy of all PI-RADS ≥3 lesions. J. Magn. Reson. Imaging 2019;49:1400-1408.

Spatial distribution of biopsy cores and the detection of intra-lesion pathologic heterogeneity.

Objectives:The objective of this study was to determine if spatial distribution of multiparametric magnetic resonance imaging–transrectal ultrasound (mpMRI-TRUS) fusion biopsy cores to the index lesion reveals trends in the detection of intra-lesion Gleason heterogeneity and a more optimal prostate biopsy strategy.Methods:Index lesion was the lesion with longest diameter on T2-weighted (T2W)-MRI. In cohort 1, fusion biopsy cores biopsies were taken in areas in the center of the target as well as 1 cm laterally on each side. For cohort 2, targeted biopsies were taken from the center of the lesion only. Heterogeneity was defined as difference in maximum Gleason score obtained from fusion cores in the center of the index lesion versus cores obtained from the periphery (cohort 1), or any difference in maximum Gleason score obtained from fusion cores targeted to the index lesion (cohort 2) compared with systematic 12 cores TRUS biopsy.Results:Ninety-nine consecutive patients (35 and 64 in cohorts 1 and 2, respectively) with median age (SD) and prostate-specific antigen (PSA) of 66.9 (±5.9) and 9.7 (±8.2) respectively, were included. Age, PSA, Prostate Imaging Reporting and Data System (PI-RADS) score, and preoperative MRI lesion size were not significantly different between cohorts. Gleason heterogeneity was observed at a significantly higher rate in cohort 1 versus cohort 2 (58% versus 24%; p = 0.041). In cohort 1, cores obtained from the center of the lesion had higher Gleason score than cores obtained from the periphery of the targeted lesion in 57% of cases.Conclusions:We demonstrate that there is observable tumor heterogeneity in biopsy specimens, and that increased number of cores, as well as cores focused on the center and periphery of the largest lesion in the prostate, provide more comprehensive diagnostic information about the patient’s clinical risk category than taking nonspecific cores targeted within the tumor.

The SmartTarget Biopsy Trial: A Prospective, Within-person Randomised, Blinded Trial Comparing the Accuracy of Visual-registration and Magnetic Resonance Imaging/Ultrasound Image-fusion Targeted Biopsies for Prostate Cancer Risk Stratification

BackgroundMultiparametric magnetic resonance imaging (mpMRI)-targeted prostate biopsies can improve detection of clinically significant prostate cancer and decrease the overdetection of insignificant cancers. It is unknown whether visual-registration targeting is sufficient or augmentation with image-fusion software is needed. ObjectiveTo assess concordance between the two methods. Design, setting, and participantsWe conducted a blinded, within-person randomised, paired validating clinical trial. From 2014 to 2016, 141 men who had undergone a prior (positive or negative) transrectal ultrasound biopsy and had a discrete lesion on mpMRI (score 3–5) requiring targeted transperineal biopsy were enrolled at a UK academic hospital; 129 underwent both biopsy strategies and completed the study. InterventionThe order of performing biopsies using visual registration and a computer-assisted MRI/ultrasound image-fusion system (SmartTarget) on each patient was randomised. The equipment was reset between biopsy strategies to mitigate incorporation bias. Outcome measurements and statistical analysisThe proportion of clinically significant prostate cancer (primary outcome: Gleason pattern ≥3+4=7, maximum cancer core length ≥4mm; secondary outcome: Gleason pattern ≥4+3=7, maximum cancer core length ≥6mm) detected by each method was compared using McNemar's test of paired proportions. Results and limitationsThe two strategies combined detected 93 clinically significant prostate cancers (72% of the cohort). Each strategy detected 80/93 (86%) of these cancers; each strategy identified 13 cases missed by the other. Three patients experienced adverse events related to biopsy (urinary retention, urinary tract infection, nausea, and vomiting). No difference in urinary symptoms, erectile function, or quality of life between baseline and follow-up (median 10.5 wk) was observed. The key limitations were lack of parallel-group randomisation and a limit on the number of targeted cores. ConclusionsVisual-registration and image-fusion targeting strategies combined had the highest detection rate for clinically significant cancers. Targeted prostate biopsy should be performed using both strategies together. Patient summaryWe compared two prostate cancer biopsy strategies: visual registration and image fusion. A combination of the two strategies found the most clinically important cancers and should be used together whenever targeted biopsy is being performed.