Risk Of Extracapsular Extension Research Articles

Extracapsular extension risk assessment using an artificial intelligence prostate cancer mapping algorithm

AbstractObjectiveThe objective of this study is to compare detection rates of extracapsular extension (ECE) of prostate cancer (PCa) using artificial intelligence (AI)‐generated cancer maps versus MRI and conventional nomograms.Materials and methodsWe retrospectively analysed data from 147 patients who received MRI‐targeted biopsy and subsequent radical prostatectomy between September 2016 and May 2022. AI‐based software cleared by the United States Food and Drug Administration (Unfold AI, Avenda Health) was used to map 3D cancer probability and estimate ECE risk. Conventional ECE predictors including MRI Likert scores, capsular contact length of MRI‐visible lesions, PSMA T stage, Partin tables, and the “PRedicting ExtraCapsular Extension” nomogram were used for comparison.Postsurgical specimens were processed using whole‐mount histopathology sectioning, and a genitourinary pathologist assessed each quadrant for ECE presence. ECE predictors were then evaluated on the patient (Unfold AI versus all comparators) and quadrant level (Unfold AI versus MRI Likert score). Receiver operator characteristic curves were generated and compared using DeLong's test.ResultsUnfold AI had a significantly higher area under the curve (AUC = 0.81) than other predictors for patient‐level ECE prediction. Unfold AI achieved 68% sensitivity, 78% specificity, 71% positive predictive value, and 75% negative predictive value. At the quadrant level, Unfold AI exceeded the AUC of MRI Likert scores for posterior (0.89 versus 0.82, p = 0.003), anterior (0.84 versus 0.80, p = 0.34), and all quadrants (0.89 versus 0.82, p = 0.002). The false negative rate of Unfold AI was lower than MRI in both the anterior (−60%) and posterior prostate (−40%).ConclusionsUnfold AI accurately predicted ECE risk, outperforming conventional methodologies. It notably improved ECE prediction over MRI in posterior quadrants, with the potential to inform nerve‐spare technique and prevent positive margins. By enhancing PCa staging and risk stratification, AI‐based cancer mapping may lead to better oncological and functional outcomes for patients.

Saline-assisted fascial exposure (SAFE) technique to improve nerve-sparing in robot-assisted laparoscopic radical prostatectomy.

To provide a summary of our initial experience and assess the impact of the Saline-Assisted Fascial Exposure (SAFE) technique on erectile function (EF), urinary continence, and oncological outcomes after Robot-Assisted Laparoscopic Radical Prostatectomy (RALP). From January 2021 to July 2022, we included patients with a baseline Sexual Health Inventory for Men (SHIM) score of ≥17 and a high probability of extracapsular extension (ECE), ranging from 21% to 73%, as per the Martini etal. nomogram. A propensity score matching was carried out at a ratio of 1:2 between patients who underwent RALP + SAFE (33) and RALP alone (66). The descriptive statistical analysis is presented. The SAFE technique was performed using two approaches, transrectal guided by micro-ultrasound or transperitoneal. Its principle entails a low-pressure injection of saline solution in the periprostatic fascia to achieve an atraumatic dissection of the neural hammock. Potency was defined as a SHIM score of ≥17 and continence as no pads per day. At follow-up intervals of 6, 13, 26, and 52 weeks, the SHIM score differed significantly between the two groups, favouring the RALP + SAFE (P = 0.01, P < 0.001, P < 0.001, and P = 0.01, respectively). These results remained significant when the mean SHIM score was assessed. As shown by the cumulative incidence curve, EF rates were higher in the RALP + SAFE compared to the RALP alone group (log-rank P < 0.001). The baseline SHIM and use of the SAFE technique were independent predictors of EF recovery. The use of the SAFE technique led to better SHIM scores at 6, 13, 26, and 52 weeks after RALP in patients at high risk of ECE who underwent a partial NS procedure.

Extracapsular extension of transitional zone prostate cancer miss-detected by multiparametric magnetic resonance imaging.

To demonstrate the importance of extracapsular extension (ECE) of transitional zone (TZ) prostate cancer (PCa), examine the causes of its missed detection by Mp-MRI, and develop a new predictive model by integrating multi-level clinical variables. This retrospective study included 304 patients who underwent laparoscopic radical prostatectomy after 12 + X needle transperineal transrectal ultrasound (TRUS)-MRI-guided targeted prostate biopsy from 2018 to 2021 in our center was performed. In this study, the incidence rates of ECE were similar in patients with MRI lesions in the peripheral zone (PZ) and TZ (P = 0.66). However, the missed detection rate was higher in patients with TZ lesions than in those with PZ lesions (P < 0.05). These missed detections result in a higher positive surgical margin rate (P < 0.05). In patients with TZ lesions, detected MP-MRI ECE may have grey areas: the longest diameters of the MRI lesions were 16.5-23.5mm; MRI lesion volumes were 0.63-2.51ml; MRI lesion volume ratios were 2.75-8.86%; PSA were 13.85-23.05ng/ml. LASSO regression was used to construct a clinical prediction model for predicting the risk of ECE in TZ lesions from the perspective of MRI and clinical features, including four variables: the longest diameter of MRI lesions, TZ pseudocapsule invasion, ISUP grading of biopsy pathology, and number of positive biopsy needles. Patients with MRI lesions in the TZ have the same incidence of ECE as those with lesions in the PZ, but a higher missed detection rate.

Validation of user-friendly models predicting extracapsular extension in prostate cancer patients

ObjectiveThere are many models to predict extracapsular extension (ECE) in patients with prostate cancer. We aimed to externally validate several models in a Japanese cohort. MethodsWe included patients treated with robotic-assisted radical prostatectomy for prostate cancer. The risk of ECE was calculated for each patient in several models (prostate side-specific and non-side-specific). Model performance was assessed by calculating the receiver operating curve and the area under the curve (AUC), calibration plots, and decision curve analyses. ResultsWe identified ECE in 117 (32.9%) of the 356 prostate lobes included. Patients with ECE had a statistically significant higher prostate-specific antigen level, percentage of positive digital rectal examination, percentage of hypoechoic nodes, percentage of magnetic resonance imaging nodes or ECE suggestion, percentage of biopsy positive cores, International Society of Urological Pathology grade group, and percentage of core involvement. Among the side-specific models, the Soeterik, Patel, Sayyid, Martini, and Steuber models presented AUC of 0.81, 0.78, 0.77, 0.75, and 0.73, respectively. Among the non-side-specific models, the memorial Sloan Kettering Cancer Center web calculator, the Roach formula, the Partin tables of 2016, 2013, and 2007 presented AUC of 0.74, 0.72, 0.64, 0.61, and 0.60, respectively. However, the 95% confidence interval for most of these models overlapped. The side-specific models presented adequate calibration. In the decision curve analyses, most models showed net benefit, but it overlapped among them. ConclusionModels predicting ECE were externally validated in Japanese men. The side-specific models predicted better than the non-side-specific models. The Soeterik and Patel models were the most accurate performing models.

Technical advances in nerve-sparing and continence preservation.

Urinary incontinence and erectile dysfunction are common after radical prostatectomy. These side effects greatly impact patients' quality of life. Therefore, surgical techniques and technology tools are constantly being developed to optimize trifecta outcomes. Here we focus on advances in nerve-sparing (NS) and continence preservation. New surgical techniques dedicated to preservation rather than reconstruction have been developed to improve urinary continence (UC) and NS. On the other hand, intraoperative assessment of prostatic and periprostatic structures has shown promising outcomes toward NS whereas avoiding omission of extracapsular extension (ECE). Likewise, neural regeneration strategies are under research to improve return of erectile function and UC. Superb outcomes after Robot-Assisted Radical Prostatectomy require a proper balance between NS and risk of ECE. Detailed anatomic knowledge together with an accurate surgical planning are cornerstone for tailoring the approach in each case.

Selection of patients for nerve sparing surgery in robot-assisted radical prostatectomy.

ContextRobot‐assisted radical prostatectomy (RARP) has become the standard surgical procedure for localized prostate‐cancer (PCa). Nerve‐sparing surgery (NSS) during RARP has been associated with improved erectile function and continence rates after surgery. However, it remains unclear what are the most appropriate indications for NSS.ObjectiveThe objective of this study is to systematically review the available parameters for selection of patients for NSS. The weight of different clinical variables, multiparametric magnetic‐resonance‐imaging (mpMRI) findings, and the impact of multiparametric‐nomograms in the decision‐making process on (side‐specific) NSS were assessed.Evidence acquisitionThis systematic review searched relevant databases and included studies performed from January 2000 until December 2020 and recruited a total of 15 840 PCa patients. Studies were assessed that defined criteria for (side‐specific) NSS and associated them with oncological safety and/or functional outcomes. Risk of bias assessment was performed.Evidence synthesisNineteen articles were eligible for full‐text review. NSS is primarily recommended in men with adequate erectile function, and with low‐risk of extracapsular extension (ECE) on the side‐of NSS. Separate clinical and radiological variables have low accuracy for predicting ECE, whereas nomograms optimize the risk‐stratification and decision‐making process to perform or to refrain from NSS when oncological safety (organ‐confined disease, PSM rates) and functional outcomes (erectile function and continence rates) were assessed.ConclusionsConsensus exists that patients who are at high risk of ECE should refrain from NSS. Several multiparametric preoperative nomograms were developed to predict ECE with increased accuracy compared with single clinical, pathological, or radiological variables, but controversy exists on risk thresholds and decision rules on a conservative versus a less‐conservative surgical approach. An individual clinical judgment on the possibilities of NSS set against the risks of ECE is warranted.Patient summaryNSS is aimed at sparing the nerves responsible for erection. NSS may lead to unfavorable tumor control if the risk of capsule penetration is high. Nomograms predicting extraprostatic tumor‐growth are probably most helpful.

Development of an Indian nomogram for predicting extracapsular extension in prostate cancer.

Introduction:The aim of our study was to develop a new Indian nomogram to estimate pathologic extracapsular extension (ECE) risk in prostate cancer, by including PI-RADS v1-based magnetic resonance imaging (MRI) ECE risk score to the clinical variables used in the Partin nomogram (PN).Materials and Methods:We analyzed 273 patients who underwent MRI of prostate and radical prostatectomy (RP). Univariate and multivariate logistic regression analyses were performed to identify predictors of ECE. We calculated the area under the receiver operating characteristic curve (AUC) for three variables used in PN and MRI ECE risk score, and a new nomogram was designed using binary logistic regression. Calibration curves assessed the agreement between the actual ECE risk and the predicted probability of the new nomogram.Results:Out of 273 patients, 123 patients (45.1) had ECE on MRI, whereas 136 patients (49.8) had ECE on final pathology. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI for predicting ECE were 76.6, 66.9, 70.0, 73.9, and 71.7 (confidence interval 95), respectively. Multivariate logistic regression analyses showed that clinical T-stage (cT), Gleason score (GS), and MRI ECE risk score remained significant. The highest and the lowest values of the AUC for single variables were 0.748 (MRI ECE risk score) and 0.636 (cT stage), respectively, and AUC for PN was 0.67. New nomogram designed using R statistical package has higher predictive accuracy (0.826) compared to PN (0.67) and good calibration.Conclusions:MRI adds incremental value to PN. A new Indian nomogram can help in the decision-making process of nerve-sparing RP. This nomogram should be used with caution as validation is pending and will require further studies.

MP62-10 UTILITY OF A MULTIVARIATE LOGISTIC REGRESSION MODEL FOR THE PREDICTION OF PROSTATE CANCER EXTRACAPSULAR EXTENSION BASED ON 3TMPMRI, CLINICAL, AND BIOPSY

You have accessJournal of UrologyProstate Cancer: Staging I (MP62)1 Apr 2020MP62-10 UTILITY OF A MULTIVARIATE LOGISTIC REGRESSION MODEL FOR THE PREDICTION OF PROSTATE CANCER EXTRACAPSULAR EXTENSION BASED ON 3TMPMRI, CLINICAL, AND BIOPSY Sohrab Afshari Mirak*, Robert Reiter, and Steven Raman Sohrab Afshari Mirak*Sohrab Afshari Mirak* More articles by this author , Robert ReiterRobert Reiter More articles by this author , and Steven RamanSteven Raman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000937.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Extracapsular extension (ECE) of prostate cancer (PCa) is a poor prognostic factor associated with progression, recurrence after treatment, and increased prostate cancer- related mortality. Accurate staging prior to radical prostatectomy is crucial in avoidance of positive margins and when planning nerve-sparing procedures. In this study, we investigated the predictive value of the clinical, biopsy & 3T multiparametric MRI (3TmpMRI) parameters using a multivariate logistic model for per-lesion detection of PCa extracapsular extension (ECE) with wholemount histopathology (WMHP) as reference. METHODS: This IRB approved, HIPAA compliant study included 575 patients with 774 true positive PCa lesions, who underwent radical prostatectomy between 7/2010-2/2019. The relationship between pathologic ECE & parameters including clinical; age, prostate specific antigen (PSA) & PSA density (PSAD), biopsy; percentage of positive systematic cores & Gleason score (GS) & 3TmpMRI; prostate volume, number of lesions per patient, size, location, level, PIRADSv2 score, laterality, apparent diffusion coefficient (ADC) value & risk of ECE on MRI was evaluated using bivariate and multivariate analysis. The accuracy of the final model was evaluated using ROC analysis. RESULTS: 27.8% (215/774), 42.9% (332/774) & 29.3% (227/774) of the lesions were PIRADSv2 score 3, 4 & 5 & 59.9% (464/774), 24.7% (191/774) & 17.7% (137/774) were low, intermediate & high risk for ECE, respectively. 23.6% (183/774) of the lesions had ECE on WMHP. On bivariate analysis higher PSA, PSAD, percentage of positive biopsy cores, biopsy GS, size, PIRADSv2 score, ADC value, risk of ECE on MRI, location (posterior), level (midgland & base), bilaterality & lower number of lesions per patient were significant for ECE prediction. The multivariate logistic model included age, PSAD, number of lesions per patient, size, location, level, PIRADSv2 score & risk of ECE on MRI. The AUC for the prediction of ECE for this model was 0.85. CONCLUSIONS: This multivariate regression model based on clinical, biopsy & 3TmpMRI parameters have a high predictive value for pathology ECE detection. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e949-e949 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sohrab Afshari Mirak* More articles by this author Robert Reiter More articles by this author Steven Raman More articles by this author Expand All Advertisement PDF downloadLoading ...

A multivariate logistic regression model based on 3T mpMRI, clinical, and biopsy parameters for the prediction of prostate cancer extracapsular extension.

27 Background: Extracapsular extension (ECE) of prostate cancer (PCa) is a poor prognostic factor associated with progression, recurrence after treatment and increased PCa- related mortality. Accurate staging prior to radical prostatectomy is crucial in avoidance of positive margins and when planning nerve-sparing procedures. This study investigated the predictive value of clinical, biopsy &amp; 3TmpMRI parameters using a multivariate logistic model for per-lesion detection of PCa ECE with wholemount histopathology (WMHP) as reference. Methods: This IRB approved, HIPAA compliant study included 575 patients with 774 true positive PCa lesions, who underwent radical prostatectomy between 7/2010-2/2019. The relationship between pathologic ECE &amp; parameters including clinical; age, prostate specific antigen (PSA) &amp; PSA density (PSAD), biopsy; percentage of positive systematic cores &amp; Gleason score (GS) &amp; 3TmpMRI; prostate volume, number of lesions per patient, size, location, level, PIRADSv2 score, laterality, apparent diffusion coefficient (ADC) value &amp; risk of ECE on MRI was evaluated using bivariate and multivariate analysis. The accuracy of the final model was evaluated using ROC analysis. Results: 27.8% (215/774), 42.9% (332/774) &amp; 29.3% (227/774) of the lesions were PIRADSv2 score 3, 4 &amp; 5 &amp; 59.9% (464/774), 24.7% (191/774) &amp; 17.7% (137/774) were low, intermediate &amp; high risk for ECE, respectively. 23.6% (183/774) of the lesions had ECE on WMHP. On bivariate analysis higher PSA, PSAD, percentage of positive biopsy cores, biopsy GS, size, PIRADSv2 score, ADC value, risk of ECE on MRI, location (posterior), level(midgland &amp; base), bilaterality &amp; lower number of lesions per patient were significant for ECE prediction. The multivariate logistic model included age, PSAD, number of lesions per patient, size, location, level, PIRADSv2 score &amp; risk of ECE on MRI. The AUC for the prediction of ECE for this model was 0.85. Conclusions: This multivariate regression model based on clinical, biopsy &amp; 3TmpMRI parameters have a high predictive value for pathology ECE detection.

Association of polymorphisms of PTEN, AKT1, PI3K, AR, and AMACR genes in patients with prostate cancer.

Polymorphic variants in the PTEN (rs2735343), PI3K (rs2699887), AKT1 (rs2494750), AR (rs17302090), and AMACR (rs3195676) genes were evaluated as possible molecular markers of susceptibility, prognosis, and progression of prostate cancer (PCa), in a case-control study. Samples consisted of 277 patients with PCa and 277 controls from Londrina, PR, Brazil. SNPs were analyzed by real-time PCR. A family history of cancer, including PCa, as well as level of schooling were risk factors for PCa. The data were obtained via logistic regression, using odds ratios with a CI 95%. The genotypes of AKT1 and AKT1+AR demonstrated an association with protection for the disease. The combination of SNPs with the histopathological tumor data between allele variants of AMACR, AKT1+AR, and AKT1+AMACR indicated an association with protection against seminal vesicle invasion. The polymorphisms AKT1+AR and PI3K+AR were associated with protection against tumor bilaterality. The genotype combinations PTEN+AMACR and PTEN+AR were associated with the risk of extracapsular extension. Of the five genes studied, two were associated with protection for PCa, four were associated with protection for some prognostic variables, and only one was associated with risk. Thus, these SNPs are candidates for markers to discriminate men with better or worse prognosis for PCa.

Impact of the Prostate Imaging Reporting and Data System, Version 2, on MRI Diagnosis for Extracapsular Extension of Prostate Cancer.

The purpose of this study is to validate the Prostate Imaging Reporting and Data System, version 2 (PI-RADSv2), in assessing extracapsular extension (ECE), compared with PI-RADS, version 1 (PI-RADSv1). A total of 210 patients with clinically localized prostate cancer underwent MRI and radical prostatectomy. Two readers independently interpreted the MR images. In PI-RADSv1, 5-point ECE risk scoring was used. In PI-RADSv2, ECE criteria included morphologic features and a tumor-capsule contact length (CL) greater than 10 mm. The diagnostic performance of each PI-RADS version and the cutoff CL were evaluated. ECE was found in 56 patients (26.7%). In PI-RADSv1, maximal accuracy was achieved with a risk score of 3 or greater. At this threshold, positive findings on PI-RADSv1 and PI-RADSv2 were identified in 21.0-34.3% and 49.0-51.4% of patients, respectively. Compared with PI-RADSv1, PI-RADSv2 had higher negative predictive values (84.9-89.1% vs 96.3-97.1%, respectively; p = 0.003 and 0.021, for each reader). PI-RADSv1 and PI-RADSv2 had positive predictive values of 56.9-70.5% and 49.1-50.5%, respectively (p = 0.025 and 0.300, respectively). Interobserver kappa values for PI-RADSv1 and PI-RADSv2 were 0.511 and 0.781, respectively. The best cutoff CL was greater than 10 mm among patients without morphologic features of ECE. For patients positive for ECE on the basis of PI-RADSv2 but not PI-RADSv1, 73.3-74.1% of prostate cancer cases with a biopsy Gleason score of 7 or less and 35.7-44.4% of cases with a biopsy Gleason score of 8 or higher were overstaged. PI-RADSv2 reduces understaging and improves interobserver agreement in ECE assessment. However, overstaging is a concern, and the biopsy Gleason score may have a complementary role in reducing overstaging.

Obesity is associated with biochemical recurrence after radical prostatectomy: A multi-institutional extended validation study

BackgroundThere are no clear data regarding the association between body mass index (BMI) and outcomes after radical prostatectomy (RP). This study aimed to investigate the association between BMI and biochemical recurrence (BCR) after RP in a large international contemporary cohort of patients with prostate cancer. MethodsWe retrospectively analyzed data from 6,519 patients who underwent RP at 5 institutions. BMI was analyzed as both a continuous and categorical variable (<25kg/m2, 25–29.9kg/m2 [overweight], and≥30kg/m2 [obese]). The associations of continuous and categorical BMI with BCR were evaluated using univariable and multivariable Cox models, and prognostic accuracy was assessed using Harrell׳s C-index. ResultsThe median BMI was 28kg/m2 (interquartile range: 24–32kg/m2); 2,155 patients (33.1%) had a BMI = 25 to 29.9kg/m2 and 2,462 patients (37.7%) had a BMI≥30kg/m². Overweight and obese status were associated with extracapsular extension (P = 0.001) and seminal vesicle invasion (P = 0.005). The median follow-up was 28 months, and the estimated 5-year BCR-free survival rates for patients with a BMI<25kg/m2, 25 to 29.9kg/m2, and≥30kg/m² were 92%, 86%, and 79%, respectively (P<0.001). Multivariable analyses (adjusted for preoperative prostate-specific antigen levels, biopsy Gleason score, and clinical stage) revealed that obesity was associated with the risk of extracapsular extension (P<0.001), seminal vesicle invasion (P<0.001), and BCR (hazard ratio: 1.37, P<0.001). BMI and obesity remained associated with BCR after adjusting for postoperative characteristics. Addition of BMI slightly increased the discrimination of the multivariable clinical prognostic model (from 79.9%–80.9%). ConclusionsOverweight and obese status was associated with adverse pathological features and BCR after RP. However, the addition of BMI did not significantly improve the prognostic accuracy of a model that was based on established predictors.

MP03-04 DOES THE INCLUSION OF NON-INDEX LESIONS AT BIOPSY IMPROVE OUR ABILITY TO PREDICT ADVERSE PATHOLOGIC OUTCOMES AT RADICAL PROSTATECTOMY? IMPLICATIONS FOR TARGETED PLUS SYSTEMATIC BIOPSY SCHEMES

You have accessJournal of UrologyProstate Cancer: Detection & Screening I1 Apr 2017MP03-04 DOES THE INCLUSION OF NON-INDEX LESIONS AT BIOPSY IMPROVE OUR ABILITY TO PREDICT ADVERSE PATHOLOGIC OUTCOMES AT RADICAL PROSTATECTOMY? IMPLICATIONS FOR TARGETED PLUS SYSTEMATIC BIOPSY SCHEMES Giorgio Gandaglia, Marco Bandini, Paolo Dell'Oglio, Nicola Fossati, Francesco Pellegrino, Giuseppe Fallara, Emanuele Zaffuto, Carlo Andrea Bravi, Luigi Nocera, Rocco Damiano, Massimo Freschi, Rodolfo Montironi, Francesco Montorsi, and Alberto Briganti Giorgio GandagliaGiorgio Gandaglia More articles by this author , Marco BandiniMarco Bandini More articles by this author , Paolo Dell'OglioPaolo Dell'Oglio More articles by this author , Nicola FossatiNicola Fossati More articles by this author , Francesco PellegrinoFrancesco Pellegrino More articles by this author , Giuseppe FallaraGiuseppe Fallara More articles by this author , Emanuele ZaffutoEmanuele Zaffuto More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Rocco DamianoRocco Damiano More articles by this author , Massimo FreschiMassimo Freschi More articles by this author , Rodolfo MontironiRodolfo Montironi More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.121AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although prostate biopsies targeted only to MRI detected lesions allow for the detection of clinically significant diseases, they would not result into a complete sampling of the entire prostate. Therefore, lower grade tumors (i.e., non-index lesions) in other areas would not be detected. We hypothesized that the presence of non-index lesions might impact on the risk of adverse outcomes at radical prostatectomy (RP). METHODS 761 PCa patients treated with RP between 2012 and 2016 were identified. All biopsy specimens were re-reviewed by two high-volume dedicated uro-pathologists. The index lesion was defined as the highest-grade core at biopsy. When multiple positive cores were present, the index lesion was defined as higher-grade disease or higher number of positive cores with higher-grade disease from the same location. Non-index lesions were defined as lower grade or lower number of positive cores in other areas. Multivariable logistic regression (MVA) analyses tested the impact of the non-index lesions and of the number of positive non-index lesion cores on the risk of extracapsular extension (ECE), seminal vesicle involvement (SVI), and positive surgical margins (PSM). AUC of the models without information on the presence of non-index lesions were compared with full models using the DeLong method. RESULTS Overall, 284 (37.5%), 83 (10.9%), and 145 (19.1%) patients had ECE, SVI, and PSM at final pathology. At MVA, the presence of non-index lesions was a predictor of ECE (Odds ratio [OR]: 2.12; P=0.001), SVI (OR: 2.75; P=0.02), and PSM (OR: 2.16; P=0.01). Similarly, the number of positive cores in the non-index lesion was associated with the risk of ECE (OR: 1.09; P=0.02), SVI (OR: 1.13; P<0.001), and PSM (OR: 1.07; P=0.01). The inclusion of information on non-index lesions improved the accuracy of the model predicting PSM (AUC: 67.0 vs. 69.4%; P=0.04). No differences in the AUCs of the base model and of the model including the presence of non-index lesions were observed for ECE (78.8 vs. 78.6%; P=0.7) and SVI (81.5 vs. 82.1%; P=0.3). CONCLUSIONS The presence of non-index lesions and the number of positive cores in the non-index lesion represent predictors of ECE, SVI, and PSM. The inclusion of these parameters improves our ability to identify patients at higher risk of PSM. A systematic sample of the prostate provides useful preoperative information on the risk of adverse pathologic outcomes and should be always considered in association with targeted biopsies. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e20 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Giorgio Gandaglia More articles by this author Marco Bandini More articles by this author Paolo Dell'Oglio More articles by this author Nicola Fossati More articles by this author Francesco Pellegrino More articles by this author Giuseppe Fallara More articles by this author Emanuele Zaffuto More articles by this author Carlo Andrea Bravi More articles by this author Luigi Nocera More articles by this author Rocco Damiano More articles by this author Massimo Freschi More articles by this author Rodolfo Montironi More articles by this author Francesco Montorsi More articles by this author Alberto Briganti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prostate cancer: Can image-guided biopsy findings evaluate risk of ECE?

Interest in multiparametric MRI (mpMRI) for pre-operative prediction of extracapsular extension (ECE) by prostate cancer is growing. As unsuspicious findings on mpMRI cannot rule out ECE, complementary predictors based on clinical and biopsy sample characteristics are needed to risk-stratify patients and plan surgery. Image-guided biopsy might be key in this endeavour.

Multiparametric magnetic resonance imaging for the assessment of extracapsular invasion and other staging parameters in patients with prostate cancer candidates for radical prostatectomy

IntroductionThe proper evaluation of the extracapsular extension (ECE), the invasion of seminal vesicles and regional lymph nodes are necessary to plan the treatment of localized prostate cancer. A model that assesses the risk of ECE in the specimen considering the clinical, histological and imaging findings is defined. Material and methodsProspective study in 85 patients with prostate cancer treated with radical prostatectomy. Prostate biopsy was performed 4 weeks before multiparametric study (mpMRI). mpMRI included T2-weighted endorectal magnetic resonance imaging (T2W-MRI), diffusion-weighted magnetic resonance imaging (DW-MRI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). The apparent diffusion coefficient (ADC) was also measured. A study of consistency (k) was assessed comparing receiver operating characteristic (ROC) curve and area under the curve (AUC), which were obtained in each case (Z). Finally, a regression model was performed to predict ECE. ResultsThe mean age was 63.7±6.9 years and the mean value of PSA 12.6±13.8. In 31.7% of cases, digital rectal examination was suspicious for malignancy. Prostatectomy specimen showed pT2a in 12 cases (14%), pT2b in 3 (3%), pT2c in 37 (43%), pT3a in 19 (22%) and pT3b 14 cases (17%). ECE was evidenced in 33 (39%) of the specimens, seminal vesicle invasion in 14 (16.5%) and pelvic node involvement in 5 patients (6%). The consistency in the evaluation of ECE (image and pathological studies) was .35 for MRI (sensitivity .33, specificity .96) and .62 for mpMRI (sensitivity .58, specificity .98). Mean value of ADC was .76±.2 in patients with ECE. This value was not associated with Gleason score (p=.2) or with PSA value (p=.6). AUC value as predictor of ECE was of 65% for MRI, 78% for mpMRI and 50% ADC (Z=.008). Univariate analysis demonstrated that ECE probability increases with each Gleason score point, whilst this probability increases 1.06 times with each PSA point, and decreases .3 times with each point of ADC. Multivariate analysis confirmed that ADC value is a slight protective factor against ECE (OR=.01; CI 95% .002–.14). The consistency in the evaluation of seminal vesicles was .43 for MRI and .67 for mpMRI. AUC was 69% and 82% respectively (Z=.02). The consistency in the evaluation of positive lymph nodes was .4 for MRI and .7 for mpMRI. AUC was 68% and 88% respectively (Z=.36). ConclusionsMultiparametric study allows to carry out a more proper preoperative evaluation of ECE than convectional MRI. The most reliable predictors of ECE are DW-MRI combined with DCE-MRI, ADC coefficient and Gleason score. The superiority of mpMRI is also demonstrated for the detection of seminal vesicles invasion, but not for the evaluation of lymph nodes invasion.

Evaluación de la invasión extracapsular y otros parámetros de estadificación mediante resonancia nuclear magnética multiparamétrica en pacientes con cáncer de próstata candidatos a prostatectomía radical

Introductionthe proper evaluation of the extracapsular extension (ECE), the invasion of seminal vesicles and regional lymph nodes are necessary to plan the treatment of localized prostate cancer. A model that assesses the risk of ECE in the specimen considering the clinical, histological and imaging findings is defined. Material and methodsprospective study in 85 patients with prostate cancer treated with radical prostatectomy. Prostate biopsy was performed 4 weeks before multiparametric study (mpMRI). mpMRI included T2-weighted endorectal magnetic resonance imaging (T2W-MRI), diffusion-weighted magnetic resonance imaging (DW-MRI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). The apparent diffusion coefficient (ADC) was also measured. A study of consistency (k) was assessed comparing receiver operating characteristic (ROC) curve and area under the curve (AUC), which were obtained in each case (Z). Finally, a regression model was performed to predict ECE. Resultsthe mean age was 63.7±6.9 years and the mean value of PSA 12.6±13.8. In 31.7% of cases, digital rectal examination was suspicious for malignancy. Prostatectomy specimen showed pT2a in 12 cases (14%), pT2b in 3 (3%), pT2c in 37 (43%), pT3a in 19(22%) and pT3b 14 cases (17%). ECE was evidenced in 33 (39%) of the specimens, seminal vesicle invasion in 14 (16.5%) and pelvic node involvement in 5 patients (6%). The consistency in the evaluation of ECE (image and pathological studies) was .35 for MRI (sensitivity .33, specificity .96) and .62 for mpMRI (sensitivity .58, specificity .98). Mean value of ADC was .76±.2 in patients with ECE. This value was not associated with Gleason score (P=.2) or with PSA value (P=.6). AUC value as predictor of ECE was of 65% for MRI, 78% for mpMRI and 50% ADC (Z=.008). Univariate analysis demonstrated that ECE probability increases with each Gleason score point, whilst this probability increases 1.06 times with each PSA point, and decreases .3 times with each point of ADC. Multivariate analysis confirmed that ADC value is a slight protective factor against ECE (OR=.01; CI 95% .002-.14). The consistency in the evaluation of seminal vesicles was .43 for MRI and .67 for mpMRI. AUC was 69% and 82% respectively (Z=.02). The consistency in the evaluation of positive lymph nodes was .4 for MRI and .7 for mpMRI. AUC was 68% and 88% respectively (Z=.36). Conclusionsmultiparametric study allows to carry out a more proper preoperative evaluation of ECE than convectional MRI. The most reliable predictors of ECE are DW-MRI combined with DCE-MRI, ADC coefficient and Gleason score. The superiority of mpMRI is also demonstrated for detection of seminal vesicles invasion, but not for the evaluation of lymph nodes invasion.

1008 MEN WITH LOW PREOPERATIVE SEXUAL FUNCTION MAY BENEFIT FROM NERVE-SPARING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized (IV)1 Apr 20131008 MEN WITH LOW PREOPERATIVE SEXUAL FUNCTION MAY BENEFIT FROM NERVE-SPARING RADICAL PROSTATECTOMY Catherine Harris, Sanoj Punnen, and Peter Carroll Catherine HarrisCatherine Harris San Francisco, CA More articles by this author , Sanoj PunnenSanoj Punnen San Francisco, CA More articles by this author , and Peter CarrollPeter Carroll San Francisco, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The benefits of nerve-sparing radical prostatectomy (RP) for post-operative sexual function are well known, however, it is unclear whether nerve-sparing has a clear benefit in men with poor pretreatment sexual function. The objective of this study was to assess the effect of nerve-sparing radical prostatectomy on urinary and sexual function in men at various levels of pretreatment sexual function with a specific focus on men with poor function prior to surgery. METHODS Men within the CaPSURE database who underwent RP and had baseline and 2 year post-treatment UCLA Prostate Cancer Index (PCI) sexual and urinary function scores were selected for the study cohort. The degree of nerve-sparing was categorized as either complete bilateral, unilateral/partial, or no nerve-sparing, and the level of pre-treatment sexual function was divided into quartiles. The cohort was divided into subgroups of nerve-sparing technique and pre-treatment sexual function. Adjusted means of sexual function (SF) and urinary function (UF) within subgroups were calculated and the differences between means were tested using analysis of covariance. A test of interaction was performed between preoperative SF and degree of nerve-sparing on postoperative SF and UF scores. RESULTS 1,322 patients met the inclusion criteria. Median patient age was 61 (range 41-79). Bilateral, unilateral, and no nerve-sparing were performed in 899, 200 and 223 men, respectively. The effects of nerve-sparing on SF differed between the quartiles of pre-RP SF (p-value <0.01). Nerve-sparing did not have an effect on SF among men in the lowest quartile of pre-RP SF score (p=0.15), but had a significant benefit on SF in the higher three quartiles (p=0.04, p<0.01, p<0.01, respectively). Alternatively, nerve-sparing improved UF in men in the lowest quartile of baseline SF. CONCLUSIONS Nerve-sparing RP improves SF in most men with the exception of those with little/no baseline function. However, UF was positively impacted by nerve-sparing in these men. Men who are suitable candidates for nerve preservation based on the risk of extra capsular extension may benefit from nerve-sparing surgery. Poorer baseline sexual function should not exclude them from such surgery. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e414 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Catherine Harris San Francisco, CA More articles by this author Sanoj Punnen San Francisco, CA More articles by this author Peter Carroll San Francisco, CA More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Defining the Risk of Extra-Capsular Extension (ECE) in Patients with Early T-stage, Node-positive, HPV-related Oropharyngeal Carcinoma

Defining the Risk of Extra-Capsular Extension (ECE) in Patients with Early T-stage, Node-positive, HPV-related Oropharyngeal Carcinoma

Active Patient Decision Making Regarding Nerve Sparing During Radical Prostatectomy: A Novel Approach

The motivation to preserve sexual function can vary widely among patients before prostatectomy. Increasing patient involvement may allow a more personalized experience and may improve satisfaction. We assessed a strategy of surgeon deference to patient choice in regard to nerve sparing to determine to what degree patients are rational actors and capable of active decision making. A total of 150 patients treated with prostatectomy participated in a standardized preoperative discussion regarding the concept of nerve sparing, extracapsular extension and the potential need for adjuvant radiation in the event of local recurrence. Each patient was given his nomogram predicted risk of extracapsular extension and then elected nerve sparing or nonnerve sparing. The corresponding procedure was performed unless grossly invasive disease was encountered. Of the 150 patients 109 chose nerve sparing (73%) and 41 chose nonnerve sparing (27%). In patients with a nomogram predicted risk of extracapsular extension less than 20%, 20% to 50% and greater than 50%, nerve sparing was elected by 88%, 41% and 25%, respectively. Patients with lower risks of extracapsular extension electing nonnerve sparing were older and had higher rates of erectile dysfunction. Empowering patients to decide on their nerve sparing status is a reasonable strategy that did not lead to a high rate of patients with a high risk of extracapsular extension electing nerve sparing. With proper counseling informed patients made reasonable decisions, and appeared to be conservative, prioritizing cancer control in the majority of instances where extracapsular extension risk was high. In addition, they may have been overly conservative in electing nonnerve sparing when the risk was low.

1331 PREOPERATIVE ERECTILE DYSFUNCTION IS ASSOCIATED WITH LARGER TUMOR VOLUMES -AN ANALYSIS FROM THE DUKE PROSTATE CENTER DATABASE

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Evaluation1 Apr 20111331 PREOPERATIVE ERECTILE DYSFUNCTION IS ASSOCIATED WITH LARGER TUMOR VOLUMES -AN ANALYSIS FROM THE DUKE PROSTATE CENTER DATABASE Masaki Kimura, Lionel Bañez, Jim Qi, Leah Gerber, Thomas Polascik, Craig Donatucci, and Judd Moul Masaki KimuraMasaki Kimura Durham, NC More articles by this author , Lionel BañezLionel Bañez Durham, NC More articles by this author , Jim QiJim Qi Durham, NC More articles by this author , Leah GerberLeah Gerber Durham, NC More articles by this author , Thomas PolascikThomas Polascik Durham, NC More articles by this author , Craig DonatucciCraig Donatucci Durham, NC More articles by this author , and Judd MoulJudd Moul Durham, NC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1151AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Among prostate cancer (PCa) patients, it has been reported that preoperative erectile dysfunction (ED) is associated with increased risk for death from causes other than PCa. It was hypothesized that ED patients were also at considerably increased risk for adverse cardiovascular events. However, the impact of preoperative ED on pathological features of PCa is unknown. We, therefore, sought to investigate the relationship between preoperative erectile function (EF) and pathological features of CaP at the time of surgery in men undergoing radical prostatectomy. METHODS We analyzed data from the Duke Prostate Center database on 625 consecutive patients with complete records including sexual function evaluations who underwent RP between 2001 and 2010. Preoperative EF was assessed using sexual function scores of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Crude and adjusted linear and logistic regression models were used to investigate the association between preoperative EF and risk for adverse pathological parameters, including high tumor volume (TV), extracapsular extension (ECE), seminal vesicle invasion (SVI) and positive surgical margins (PSM). Preoperative EF was adjusted for age, race, preoperative PSA, clinical T stage, and prostatectomy type. RESULTS Of 625 patients, 201 (32.2%) men underwent retropubic RP, 136 (21.8%) underwent perineal RP, and 288 (46.0%) underwent robotic-assisted laparoscopic RP. Bilateral, unilateral, non-nerve-sparing procedures were performed in 316 (50.5%), 168 (26.9%), and 141 (22.6%) patients, respectively. There was no difference with regards to distribution of age, race, PSA, clinical stage and prostatectomy type between patients with normal EF and those with ED. In univariate analyses, higher preoperative EF scores were significantly associated with slightly decreased risk for ECE (OR 0.99; 95%CI 0.98-1.00; P=0.038), and lower TV (coef, −0.04; 95%CI, −0.07–0.09; P=0.012). After adjusting for covariates, only TV (coef, −0.04; 95%CI, −0.08–0.05; P=0.024) was found to be negatively associated with EF. CONCLUSIONS Men with decreased EF were more likely to have larger tumors compared to men with higher EF scores. These results suggest that, apart from increased risk for non-PCa mortality in men with ED, the risk for adverse PCa outcomes may also be negatively impacted by ED or ED-related comorbidities. Alternatively, larger tumors may also contribute to ED locally via pressure effects or neural infiltration. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e532 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Masaki Kimura Durham, NC More articles by this author Lionel Bañez Durham, NC More articles by this author Jim Qi Durham, NC More articles by this author Leah Gerber Durham, NC More articles by this author Thomas Polascik Durham, NC More articles by this author Craig Donatucci Durham, NC More articles by this author Judd Moul Durham, NC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...