Extracapsular Extension Score Research Articles

A novel nomogram predicting lymph node invasion among patients with prostate cancer: The importance of extracapsular extension at multiparametric magnetic resonance imaging

PurposeTo develop a novel risk tool that allows the prediction of lymph node invasion (LNI) among patients with prostate cancer (PCa) treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND). MethodsWe retrospectively identified 742 patients treated with RARP + ePLND at a single center between 2012 and 2018. All patients underwent multiparametric magnetic resonance imaging (mpMRI) and were diagnosed with targeted biopsies. First, the nomogram published by Briganti et al. was validated in our cohort. Second, three novel multivariable logistic regression models predicting LNI were developed: (1) a complete model fitted with PSA, ISUP grade groups, percentage of positive cores (PCP), extracapsular extension (ECE), and Prostate Imaging Reporting and Data System (PI-RADS) score; (2) a simplified model where ECE score was not included (model 1); and (3) a simplified model where PI-RADS score was not included (model 2). The predictive accuracy of the models was assessed with the receiver operating characteristic-derived area under the curve (AUC). Calibration plots and decision curve analyses were used. ResultsOverall, 149 patients (20%) had LNI. In multivariable logistic regression models, PSA (OR: 1.03; P= 0.001), ISUP grade groups (OR: 1.33; P= 0.001), PCP (OR: 1.01; P= 0.01), and ECE score (ECE 4 vs. 3 OR: 2.99; ECE 5 vs. 3 OR: 6.97; P< 0.001) were associated with higher rates of LNI. The AUC of the Briganti et al. model was 74%. Conversely, the AUC of model 1 vs. model 2 vs. complete model was, respectively, 78% vs. 81% vs. 81%. Simplified model 1 (ECE score only) was then chosen as the best performing model. A nomogram to calculate the individual probability of LNI, based on model 1 was created. Setting our cut-off at 5% we missed only 2.6% of LNI patients. ConclusionsWe developed a novel nomogram that combines PSA, ISUP grade groups, PCP, and mpMRI-derived ECE score to predict the probability of LNI at final pathology in RARP candidates. The application of a nomogram derived cut-off of 5% allows to avoid a consistent number of ePLND procedures, missing only 2.6% of LNI patients. External validation of our model is needed.

A novel nomogram to identify candidates for active surveillance amongst patients with International Society of Urological Pathology (ISUP) Grade Group (GG) 1 or ISUP GG2 prostate cancer, according to multiparametric magnetic resonance imaging findings

ObjectivesTo develop a novel nomogram to identify candidates for active surveillance (AS) that combines clinical, biopsy and multiparametric magnetic resonance imaging (mpMRI) findings; and to compare its predictive accuracy to, respectively: (i) Prostate Cancer Research International: Active Surveillance (PRIAS) criteria, (ii) Johns Hopkins (JH) criteria, (iii) European Association of Urology (EAU) low‐risk classification, and (iv) EAU low‐risk or low‐volume with International Society of Urological Pathology (ISUP) Grade Group (GG) 2 classification.Patients and MethodsWe selected 1837 patients with ISUP GG1 or GG2 prostate cancer (PCa), treated with radical prostatectomy (RP) between 2012 and 2018. The outcome of interest was the presence of unfavourable disease (i.e., clinically significant PCa [csPCa]) at RP, defined as: ISUP GG 3 and/or pathological T stage (pT) ≥3a and/or pathological N stage (pN) 1. First, logistic regression models including PRIAS, JH, EAU low‐risk, and EAU low‐risk or low‐volume ISUP GG2 binary classifications (not eligible vs eligible) were used. Second, a multivariable logistic regression model including age, prostate‐specific antigen density (PSA‐D), ISUP GG, and the percentage of positive cores (Model 1) was fitted. Third, Prostate Imaging‐Reporting and Data System (PI‐RADS) score (Model 2), extracapsular extension (ECE) score (Model 3) and PI‐RADS + ECE score (Model 4) were added to Model 1. Only variables associated with higher csPCa rates in Model 4 were retained in the final simplified Model 5. The area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses were used.ResultsOf the 1837 patients, 775 (42.2%) had csPCa at RP. Overall, 837 (47.5%), 986 (53.7%), 348 (18.9%), and 209 (11.4%) patients were eligible for AS according to, respectively, the EAU low‐risk, EAU low‐risk or low‐volume ISUP GG2, PRIAS, and JH criteria. The proportion of csPCa amongst the EAU low‐risk, EAU low‐risk or low‐volume ISUP GG2, PRIAS and JH candidates was, respectively 28.5%, 29.3%, 25.6% and 17.2%. Model 4 and Model 5 (in which only PSA‐D, ISUP GG, PI‐RADS and ECE score were retained) had a greater AUC (0.84), compared to the four proposed AS criteria (all P &lt; 0.001). The adoption of a 25% nomogram threshold increased the proportion of AS‐eligible patients from 18.9% (PRIAS) and 11.4% (JH) to 44.4%. Moreover, the same 25% nomogram threshold resulted in significantly lower estimated risks of csPCa (11.3%), compared to PRIAS (Δ: −14.3%), JH (Δ: −5.9%), EAU low‐risk (Δ: −17.2%), and EAU low‐risk or low‐volume ISUP GG2 classifications (Δ: −18.0%).ConclusionThe novel nomogram combining clinical, biopsy and mpMRI findings was able to increase by ~25% and 35% the absolute frequency of patients suitable for AS, compared to, respectively, the PRIAS or JH criteria. Moreover, this nomogram significantly reduced the estimated frequency of csPCa that would be recommended for AS compared to, respectively, the PRIAS, JH, EAU low‐risk, and EAU low‐risk or low‐volume ISUP GG2 classifications.

PD57-03 NOMOGRAM INCLUDING MAXIMUM CORE LENGTH AT BIOPSY AND INDEX LESION SIZE AT MPMRI BEST PREDICTS THE EXTRACAPSULAR EXTENSION OF PROSTATE CANCER AT WHOLE-MOUNT SECTIONS OF RADICAL PROSTATECTOMIES

You have accessJournal of UrologyProstate Cancer: Staging II (PD57)1 Apr 2020PD57-03 NOMOGRAM INCLUDING MAXIMUM CORE LENGTH AT BIOPSY AND INDEX LESION SIZE AT MPMRI BEST PREDICTS THE EXTRACAPSULAR EXTENSION OF PROSTATE CANCER AT WHOLE-MOUNT SECTIONS OF RADICAL PROSTATECTOMIES Francesco Sanguedolce*, Jose Daniel Subiela Henriquez, Luisa Granados Palacio, Jhonatan Hernandez Mancera, Maria Jose Martinez Barcina, Jose Calderon Cortez, Territo Angelo, Palou Redorta Joan, and Breda Alberto Francesco Sanguedolce*Francesco Sanguedolce* More articles by this author , Jose Daniel Subiela HenriquezJose Daniel Subiela Henriquez More articles by this author , Luisa Granados PalacioLuisa Granados Palacio More articles by this author , Jhonatan Hernandez ManceraJhonatan Hernandez Mancera More articles by this author , Maria Jose Martinez BarcinaMaria Jose Martinez Barcina More articles by this author , Jose Calderon CortezJose Calderon Cortez More articles by this author , Territo AngeloTerrito Angelo More articles by this author , Palou Redorta JoanPalou Redorta Joan More articles by this author , and Breda AlbertoBreda Alberto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000967.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The accuracy of mpMRI in predicting extracapsular extension (ECE) of prostate cancer (PCa) is limited. The PIRADS scoring system includes the 15 mm index lesion (IL) size as a cut-off to distinguish between scores 4 and 5, and it was introduced for its relationship to a higher risk of extracapsular extension (ECE). We have analysed clinical and radiological parameters to select and integrate the most relevant features in a new nomogram for the prediction of ECE. METHODS: From 01/2013 to 12/2017, 128 patients had an mpMRI (T2W, DWI and DCE) before undertaking a radical prostatectomy (RP) at our institution. Clinical parameters included PSA, PSA density (PSAd), clinical stage (cT), ISUP grade group (Gg) and maximum length of cancer (MLC) at TRUS biopsy; variables collected at mpMRI involved index lesion size (IL), length of capsular contact (LCC),PIRADS v2 score, overall prostate LIKERT score, ESUR ECE score and LIKERT ECE score. Reference standard was the histology features at whole-mount specimen sections. Two experienced radiologists retrospectively reviewed the imaging studies blinded to the final histology. Variables resulting associated to ECE at univariate analysis were dichotomised as appropriate by identifying cut-off values at ROC curve (continuous variables) and Kundel test (categorical/nominal variables). Multivariate logistic regression was performed with the step-wise method; the statistically significant variables associated to ECE were included in a nomogram calibrated with the Hosmer-Lomeshow and R2 test. Inter-observer variabilities between the mpMRI readings of the two radiologists were assessed with the Intraclass Correlation Coefficient (ICC). RESULTS: Variables introduced in the multivariate model resulted to be the cT (<T2≥), Gg (<7≥), MLC (<5.5≥ mm), IL (<11≥ mm), PSAd (<0.26≥), PIRADS (≤4>), ESUR (≤2>), LIKERT (≤4>). The variables which finally were entered in the nomogram included the cT, MLC and IL. The probability for ECE with the combination of the three variables was 81.8%, the AUC of the model in a ROC analysis was 0.84 [95%CI(0.75-0.91)], p<0.001, and the calibration analysis resulted in a Hosmer-Lemeshow test p=0.985 and a R2=56.52%. ICC were good for PIRADS, ESUR and overall/ECE LIKERT (0.752, 0.810, 0.834, 0.857, respectively), and substantial for IL size (0.916). CONCLUSIONS: The combination of clinical and mpMRI features best predicts ECE at radical prostatectomy. The 15 mm cut-off distinguishing PIRADS score 4 to 5 should be lowered Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1194-e1194 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francesco Sanguedolce* More articles by this author Jose Daniel Subiela Henriquez More articles by this author Luisa Granados Palacio More articles by this author Jhonatan Hernandez Mancera More articles by this author Maria Jose Martinez Barcina More articles by this author Jose Calderon Cortez More articles by this author Territo Angelo More articles by this author Palou Redorta Joan More articles by this author Breda Alberto More articles by this author Expand All Advertisement PDF downloadLoading ...

The Impact of Magnetic Resonance Imaging on Prediction of Extraprostatic Extension and Prostatectomy Outcome in Patients with Low-, Intermediate- and High-Risk Prostate Cancer: Try to Find a Standard.

To investigate the value of multiparametric magnetic resonance imaging (mpMRI) and to predict extracapsular extension (ECE), seminal vesicle (SV) infiltration, and a negative surgical margin (SM) status at radical prostatectomy (RP) for different prostate cancer (PC) risk groups. In the study, 805 men underwent 3 tesla mpMRI without endorectal coil before MRI/transrectal ultrasonography-fusion guided prostate biopsy. MRIs were analyzed using the prostate imaging reporting and data system. The cohort was classified into risk groups according to National Comprehensive Cancer Network (NCCN) criteria. Of 132 men who subsequently underwent RP, pathologic stage and SM status at RP were used as reference. Retrospectively, we investigated a European Society of Urogenital Radiology (ESUR) score for ECE and SV-infiltration. Statistical analyses included regression analyses, receiver operating characteristics (ROC), and Youden Index to assess an ESUR-score cutoff. Area under the curve in ROC curve analyses was 0.82 for ESUR-ECE score to detect pT(3a)-disease and 0.77 for ESUR-SV score for pT(3b). Using a cutoff of 4 for ECE and of 2 for SV, the positive predictive value of the ECE-score for harboring pT(3) was 50.0%, 90.0%, and 88.8% for the low-, intermediate- and high-risk cohort. Retrospectively, the use of the ESUR-ECE score preoperatively would have changed the initial surgical plan, according to NCCN criteria, in 31.1% of patients. In the high-risk subgroup, 9/35 (25.7%) patients were correctly assessed as not harboring pT(3) by imaging (ECE score <4), and would have allowed secure robot-assisted radical prostatectomy and nerve-sparing surgery (NSS). When T3 suspicion on preoperative MRI would be taken into account, intraoperative frozen-sections (IFS) might avoid positive SM in 12/18 high-risk patients and an oncologic secure NSS in 8/20 intermediate-risk patients. Prediction of pT(3) disease is crucial to plan NSS and to achieve negative SM in RP. Standardized ECE scoring on mpMRI is an independent predictor of pT(3) and may help to plan RP with oncologic security, even in high-risk patients. In addition, it allows more accurate selection of a subgroup of patients for systematic and MRI-guided IFS.