Magnetic Resonance Imaging-transrectal Ultrasound Fusion Research Articles

Detection of anterior prostate cancer using a magnetic resonance imaging-transrectal ultrasound fusion biopsy in cases with initial biopsy and history of systematic biopsies

BackgroundProstate cancer in the anterior region may be missed on a transrectal systematic biopsy (SBx). Therefore, this study aimed to evaluate the performance of magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion targeted biopsy (TBx) in detecting anterior region cancer in patients with a history of SBxs. MethodsProstate biopsies were performed in 224 patients after multiparametric MRI, among whom 119 patients with prostate imaging reporting and data system (PI-RADS version 2) scores of 3 to 5 underwent MRI-TRUS fusion TBxs. Afterward, cancer detection rates (CDRs) and TBx-positive core regions were compared by categorizing patients into those with or without a history of SBxs. ResultsTotal CDR was 68.8% (44/64 cases) in the initial biopsy group (Initial-Bx group) and 47.3% (26/55 cases) in the previous-negative-systematic biopsy group (Pre-Neg-SBx group) (P = 0.018). Interestingly, both TBx- and SBx-core positive cases were more common in the Initial-Bx group than in the Pre-Neg-SBx group (Initial-Bx group: 75% [33/44 cases] vs. Pre-Neg-SBx group: 42.3% [11/26 cases], P = 0.006). However, only TBx-core positive cases were more common in the Pre-Neg-SBx group than in the Initial-Bx group (Initial-Bx group: 11.4% [5/44 cases] vs. Pre-Neg-SBx group: 30.8% [8/26 cases], P = 0.043). In addition, the proportion of anterior lesions detected by TBx cores was higher in the Pre-Neg-SBx group than in the Initial-Bx group (Initial-Bx group: 26.3% [10/38 cases] vs. Pre-Neg-SBx group: 52.6% [10/19 cases], P = 0.049). ConclusionUsing MRI-TRUS fusion TBx in the evaluation of previously negative SBx cases improved the detection rate of anterior lesions, which might have been missed in previous SBxs. Especially in patients with a history of SBxs mpMRI should be performed to screen for anterior lesions.

Usefulness of LacdiNAc-glycosylated Prostate-specific Antigen Density for Predicting Pathological Findings of Magnetic Resonance Imaging-transrectal Ultrasound Fusion Image-guided Prostate Biopsy for the Patients With Highest Prostate Imaging Reporting and Data System Category ≥3.

This study aimed to evaluate the usefulness of the LDN-PSA (LacdiNAc-glycosylated-prostate specific antigen) in detecting clinically significant prostate cancer in patients suspected of having clinically significant prostate cancer on multiparametric magnetic resonance imaging. Patients with prostate specific antigen levels ranging between 3.0 ng/mL and 20 ng/mL and suspicious lesions with PI-RADS (Prostate Imaging-Reporting and Data System) category ≥3 were included prospectively. The LDN-PSA was measured using an automated 2-step Wisteria floribunda agglutinin lectin-anti-prostate specific antigen antibody sandwich immunoassay. Two hundred four patients were included. Clinically significant prostate cancer was detected in 105 patients. On multivariable logistic regression analysis, prostate specific antigen density (OR 1.61, P = .010), LDN-PSAD (OR 1.04, P = .012), highest PI-RADS category (3 vs 4, 5; OR 14.5, P < .0001), and location of the lesion with highest PI-RADS category (transition zone vs peripheral zone) (OR 0.34, P = .009) were significant risk factors for detecting clinically significant prostate cancer. Among the patients with the highest PI-RADS category 3 (n=113), clinically significant prostate cancer was detected in 28 patients. On multivariable logistic regression analysis to predict the detection of clinically significant prostate cancer in patients with the highest PI-RADS category 3, age (OR 1.10, P = .026) and LDN-PSAD (OR 1.07, P < .0001) were risk factors for detecting clinically significant prostate cancer. LDN-PSAD would be a biomarker for detecting clinically significant prostate cancer in patients with prostate specific antigen levels ≤20 ng/mL and suspicious lesions with PI-RADS category ≥3. The use of LDN-PSAD as an adjunct to the use of prostate specific antigen levels would avoid unnecessary biopsies in patients with the highest PI-RADS category 3. Multi-institutional studies with large population are recommended.

Biopsy-Integrated 3D Magnetic Resonance Imaging Modeling of Prostate Cancer and Its Application for Gleason Grade and Tumor Laterality Assessment.

Grade Group assessed using Gleason combined score and tumor extent is a main determinant for risk stratification and therapeutic planning of prostate cancer. To develop a 3-dimensional magnetic resonance imaging (MRI) model regarding Grade Group and tumor extent in collaboration with uroradiologists and uropathologists for optimal treatment planning for prostate cancer. We studied the data from 83 patients with prostate cancer who underwent multiparametric MRI and subsequent MRI-transrectal ultrasound fusion biopsy and radical prostatectomy. A 3-dimensional MRI model was constructed by integrating topographic information of MRI-based segmented lesions, biopsy paths, and histopathologic information of biopsy specimens. The multiparametric MRI-integrated Grade Group and laterality were assessed by using the 3-dimensional MRI model and compared with the radical prostatectomy specimen. The MRI-defined index tumor was concordant with radical prostatectomy in 94.7% (72 of 76) of cases. The multiparametric MRI-integrated Grade Group revealed the highest agreement (weighted κ, 0.545) and a significantly higher concordance rate (57.9%) than the targeted (47.8%, P = .008) and systematic (39.4%, P = .01) biopsies. The multiparametric MRI-integrated Grade Group showed significantly less downgrading rates than the combined biopsy (P = .001), without significant differences in upgrading rate (P = .06). The 3-dimensional multiparametric MRI model estimated tumor laterality in 66.2% (55 of 83) of cases, and contralateral clinically significant cancer was missed in 9.6% (8 of 83) of cases. The tumor length measured by multiparametric MRI best correlated with radical prostatectomy as compared with the biopsy-defined length. The 3-dimensional model incorporating MRI and MRI-transrectal ultrasound fusion biopsy information easily recognized the spatial distribution of MRI-visible and MRI-nonvisible cancer and provided better Grade Group correlation with radical prostatectomy specimens but still requires validation.

Multiparametric Magnetic Resonance Imaging for the Detection of Clinically Significant Prostate Cancer: What Urologists Need to Know. Part 4: Transperineal Magnetic Resonance–Ultrasound Fusion Guided Biopsy Using Local Anesthesia

BackgroundTransperineal magnetic resonance imaging–transrectal ultrasound fusion guided biopsy (MFGB) is an increasingly popular technique due to increasing rates of biopsy-related infections. However, its widespread implementation has been hampered by the supposed necessity of epidural or general anesthesia. ObjectiveTo demonstrate the technique, feasibility, and results of transperineal MFGB under local anesthesia, in an ambulatory setting without the administration of prophylactic antibiotics. Design, setting, and participantsThis single-center study enrolled consecutive biopsy-naïve men with a clinical suspicion of prostate cancer into a prospective database between November 2015 and November 2020. Men with Prostate Imaging Reporting and Data System (PI-RADS) version 2 scores 3–5 underwent transperineal MFGB. Surgical procedureTransperineal MFGB was performed in an ambulatory setting under local anesthesia by a single operator. MeasurementsProcedure-associated adverse events were recorded. Patient discomfort during both the local anesthesia and the biopsy procedure was determined using a visual analogic scale (0–10). Detection rates of grade group (GG) ≥2 prostate cancer and the proportion of men with GG 1 cancer were assessed. Results and limitationsA total of 1097 eligible men underwent transperineal MFGB. The complication rate was 0.73% (8/1097); complications comprised five (0.46%) urinary tract infections including one hospitalization and three (0.27%) urinary retentions. In 735 men, the median pain scores were 2 (interquartile range [IQR] 2–3) for the local anesthesia procedure and 1 (IQR 0-2) for the biopsy. Prostate cancer was detected in 84% (926/1097) of men; 66% (723/1097) had GG ≥2 and 19% (203/1097) GG 1. ConclusionsTransperineal MFGB can safely be performed as an outpatient procedure under local anesthesia in an ambulatory setting. The detection rate of clinically significant prostate cancer is high, and biopsy is well tolerated. Although no antibiotic prophylaxis was used, the rate of infectious complications is practicably negligible. Patient summaryThis article shows how tissue samples (biopsies) can accurately be obtained from suspicious regions seen on prostate magnetic resonance imaging via needles inserted in the perineum (skin between the scrotum and the anus) in men with suspected prostate cancer. This technique appears to be very well tolerated under local anesthesia and has a lower risk of infection without antibiotic prophylaxis than the more common biopsy route through the rectum, with antibiotics.

Detection Rate of Prostate Cancer by Using Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Image-Guided Prostate Biopsy at Phramongkutklao Hospital

Objective: To determine the accuracy of prostate cancer detection by using magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion image-guided prostate biopsy. Materials and Methods: Retrospective data were collected from the patients that underwent targeted prostate biopsy guided by MRI-TRUS fusion imaging of the prostate between January 2017 and October 2018. The data including age, serum prostate-specific antigen (PSA) levels, PSA density, prostate size, lesion size from multiparametric magnetic resonance imaging of the prostate (mpMRI), Prostate Imaging and Reporting Archiving Data System score (PI-RADS), number of targeted core biopsy, and result from the pathological diagnosis were collected. Detection rate of prostate cancer was analyzed. Results: Ninety-five prostate cancer suspected patients underwent prostate biopsy for 143 lesions. Patients’ analyses showed better overall detection rate of prostate cancer from the MRI-TRUS fusion image-guided prostate biopsy compared to the extended 12-core systematic biopsy at 49.5% versus 17.9%. Significant prostate cancer with a Gleason score of more than 6 was detected by MRI-TRUS fusion image-guided prostate biopsy at 33.7%. Prostate cancer detection rates from MRI-TRUS fusion image-guided prostate biopsy categorized by PI-RADS score 3, 4, and 5 were 21%, 48%, and 74%, respectively, which showed statistically significant detection rate with higher PI-RADS score (p&lt;0.001). Conclusion: The present study showed better prostate cancer detection rate using MRI-TRUS fusion image-guide prostate biopsy with correlation to higher PI-RADS score. Keywords: Gleason score; PI-RADS score; mpMRI; MRI-TRUS fusion image-guided prostate biopsy

The Prostate Health Index aids multi-parametric MRI in diagnosing significant prostate cancer

To evaluate the performance of the Prostate Health Index (PHI) in magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion prostate biopsy for the detection of clinically significant prostate cancer (csPCa). We prospectively enrolled 164 patients with at least one Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) ≥ 3 lesions who underwent MRI-TRUS fusion prostate biopsy. Of the PSA-derived biomarkers, the PHI had the best performance in predicting csPCa (AUC 0.792, CI 0.707–0.877) in patients with PI-RADS 4/5 lesions. Furthermore, the predictive power of PHI was even higher in the patients with PI-RADS 3 lesions (AUC 0.884, CI 0.792–0.976). To minimize missing csPCa, we used a PHI cutoff of 27 and 7.4% of patients with PI-RADS 4/5 lesions could have avoided a biopsy. At this level, 2.0% of cases with csPCa would have been missed, with sensitivity and NPV rates of 98.0% and 87.5%, respectively. However, the subgroup of PI-RADS 3 was too small to define the optimal PHI cutoff. PHI was the best PSA-derived biomarker to predict csPCa in MRI-TRUS fusion prostate biopsies in men with PI-RADS ≥ 3 lesions, especially for the patients with PI-RADS 3 lesions who gained the most value.

Deep Learning for Real-time, Automatic, and Scanner-adapted Prostate (Zone) Segmentation of Transrectal Ultrasound, for Example, Magnetic Resonance Imaging–transrectal Ultrasound Fusion Prostate Biopsy

BackgroundAlthough recent advances in multiparametric magnetic resonance imaging (MRI) led to an increase in MRI-transrectal ultrasound (TRUS) fusion prostate biopsies, these are time consuming, laborious, and costly. Introduction of deep-learning approach would improve prostate segmentation. ObjectiveTo exploit deep learning to perform automatic, real-time prostate (zone) segmentation on TRUS images from different scanners. Design, setting, and participantsThree datasets with TRUS images were collected at different institutions, using an iU22 (Philips Healthcare, Bothell, WA, USA), a Pro Focus 2202a (BK Medical), and an Aixplorer (SuperSonic Imagine, Aix-en-Provence, France) ultrasound scanner. The datasets contained 436 images from 181 men. Outcome measurements and statistical analysisManual delineations from an expert panel were used as ground truth. The (zonal) segmentation performance was evaluated in terms of the pixel-wise accuracy, Jaccard index, and Hausdorff distance. Results and limitationsThe developed deep-learning approach was demonstrated to significantly improve prostate segmentation compared with a conventional automated technique, reaching median accuracy of 98% (95% confidence interval 95–99%), a Jaccard index of 0.93 (0.80–0.96), and a Hausdorff distance of 3.0 (1.3–8.7) mm. Zonal segmentation yielded pixel-wise accuracy of 97% (95–99%) and 98% (96–99%) for the peripheral and transition zones, respectively. Supervised domain adaptation resulted in retainment of high performance when applied to images from different ultrasound scanners (p > 0.05). Moreover, the algorithm’s assessment of its own segmentation performance showed a strong correlation with the actual segmentation performance (Pearson’s correlation 0.72, p < 0.001), indicating that possible incorrect segmentations can be identified swiftly. ConclusionsFusion-guided prostate biopsies, targeting suspicious lesions on MRI using TRUS are increasingly performed. The requirement for (semi)manual prostate delineation places a substantial burden on clinicians. Deep learning provides a means for fast and accurate (zonal) prostate segmentation of TRUS images that translates to different scanners. Patient summaryArtificial intelligence for automatic delineation of the prostate on ultrasound was shown to be reliable and applicable to different scanners. This method can, for example, be applied to speed up, and possibly improve, guided prostate biopsies using magnetic resonance imaging–transrectal ultrasound fusion.

Role of magnetic resonance imaging-transrectal ultrasound fusion targeted biopsy in the detection of prostate cancer in biopsy-naïve men: A literature based meta-analysis of randomized trials.

70 Background: Magnetic Resonance Imaging-Transrectal Ultrasound (MRI/TRUS) fusion targeted biopsy (TB) has been demonstrated to increase detection rates (DRs) of prostate cancer (PCa) in repeat-biopsy setting. However, its role in biopsy-naïve men remains controversial. We performed a meta-analysis based on well-designed randomized controlled trials (RCTs) to compare the diagnostic accuracy of MRI/TRUS fusion TB and systematic biopsy (SB) in the detection of PCa in biopsy-naïve men. Methods: A systematic review of PubMed (Medline), Embase, Ovid and the Cochrane Library up to 1st October, 2018 was conducted. The statistical analyses were performed with Revman 5.3. We compared the diagnostic accuracy between the intervention group (assisted with fusion TB) and the control group (SB only) by calculating the risk ratio (RR) with 95% confidence intervals (CIs) of overall PCa and clinically significant PCa (csPCa) DRs. Subgroup analysis was performed to highlight the independent role of MRI/TRUS fusion TB alone or combining fusion TB and SB together in the detection of PCa. Results: Six RCTs with 2187 participants were evaluated for the DRs of overall PCa. Pooled analysis revealed slight higher DRs of 62.7% (687/1095) in the intervention group compared with that of 41.3% (451/1092) in the control group (RR 1.40, 95% CI: 1.00-1.95). Four studies with 962 participants were evaluated for the DRs of csPCa. There is a trend favoring the intervention group which detected more csPCa (42.8%, 206/481) compared with SB in the control group (31.6%, 152/481) but with no significant difference (RR 1.36, 95% CI: 0.95-1.95). Subgroup analysis revealed fusion TB alone with less biopsy cores may equal the DRs of csPCa compared with SB alone (RR 1.24, 95% CI: 0.79-1.93). However, the DRs of overall PCa when combining MRI/TRUS fusion TB and SB was comparable to that applying SB alone (RR 1.48, 95% CI: 0.99-2.22). Conclusions: MRI/TRUS fusion TB may obtain similar csPCa DRs with less biopsy cores. But currently there was no enough evidence showing fusion TB can help significantly improve overall PCa or csPCa DRs compared with SB alone in biopsy-naïve men.

Multiparametric magnetic resonance imaging-transrectal ultrasound fusion biopsies increase the rate of cancer detection in populations with a low incidence of prostate cancer.

PurposeTo prospectively evaluate the diagnostic yield of multiparametric magnetic resonance imaging (mpMRI)-fusion, transrectal ultrasound (TRUS)-guided prostate biopsies for detection of prostate cancer in an Asian population with a low incidence of prostate cancer.Materials and MethodsA total of 131 males with suspected prostate cancer were recruited to undergo fusion biopsy with the Artemis prostate fusion biopsy device (Eigen, Grass Valley, CA, USA). All patients underwent standard 12-core systematic biopsies in addition to biopsies targeted at the mpMRI-identified abnormal regions. Yield from the standard cores was compared with that from the targeted cores. Gleason scores of 4+3 or higher were considered significant.ResultsThe mean age of the patients was 63.54±7.96 years and the mean prostate-specific antigen value was 9.75±5.35 ng/mL. A total of 36 patients had cancer, of which 3 (8.3%) were detected only on standard cores and 3 (8.3%) only on targeted cores. Of the clinically significant cancers (n=30), targeted biopsy detected a higher number (28/30, 93.3%) than standard biopsy (21/30, 70.0%). A total of 6 of 8 cancers (75.0%) that were insignificant on standard biopsy were upgraded to significant cancer on targeted cores.ConclusionsEight percent of cancers were detected only on MRI-TRUS fusion-targeted biopsies, whereas the method upgraded more than two-thirds of insignificant cancers to significant cancers. Fusion biopsies thus provide incremental information over standard TRUS biopsies in the diagnosis of significant prostate cancer in populations with a low incidence of prostate cancer.

A review of optimal prostate biopsy: indications and techniques.

Prostate biopsy is the gold standard diagnostic technique for the detection of prostate cancer. Patient selection for prostate biopsy is complex and is influenced by emerging use of prebiopsy imaging. The introduction of the magnetic resonance imaging (MRI)–transrectal ultrasound (TRUS) fusion prostate biopsy has clear advantages over the historical standard of care. There are several biopsy techniques currently utilized with unique advantages and disadvantages. We review and summarize the current body of literature pertaining to when and how a prostate biopsy should be performed. We discuss current recommendations regarding patient selection for biopsy and discuss future directions regarding prebiopsy imaging. We offer a description of the MRI–TRUS fusion biopsy technique and a comparison of many of the currently available fusion software platforms. Articles pertaining to the title were obtained via PubMed index search with relevant keywords supplemented with personal collection of related publications. Prostate biopsy should be considered for patients with gross digital rectal exam (DRE) abnormality, patients with a prostate-specific antigen (PSA) greater than 4 ng/ml, and concomitant risk factors for prostate cancer or patients with lesions identified on multiparametric MRI (mpMRI) with Prostate Imaging Reporting and Data System 2 (PI-RADS2) score of 4 or 5. MRI–TRUS fusion biopsy has demonstrated advantages in cancer detection when compared with TRUS-guided biopsy. There are currently several fusion software platforms available with a variety of biopsy approaches. Future efforts should detail the role of prebiopsy imaging as a triage tool for prostate biopsy. Consensus should be sought regarding the preferred modality of fusion biopsy. Additional data describing each fusion software platform would enable a more rigorous comparison of platform sensitivities.

Magnetic resonance imaging-transrectal ultrasound fusion image-guided prostate biopsy: Current status of the cancer detection and the prospects of tailor-made medicine of the prostate cancer.

Multi-parametric magnetic resonance imaging (mpMRI) has been increasingly used to diagnose clinically significant prostate cancer (csPCa) because of its growing availability and its ability to combine anatomical and functional data. Magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion imaging provides MRI information with TRUS images for prostate biopsies. This technique combines the superior sensitivity of MRI for targeting suspicious lesions with the practicality and familiarity of TRUS. MRI-TRUS fusion image-guided prostate biopsy is performed with different types of image registration (rigid vs. elastic) and needle tracking methods (electromagnetic tracking vs. mechanical position encoders vs. image-based software tracking). A systematic review and meta-analysis showed that MRI-targeted biopsy detected csPCa at a significantly higher rate than did TRUS-guided biopsy, while it detected significantly fewer cases of insignificant PCas. In addition to the high accuracy of MRI-targeted biopsy for csPCa, localization of csPCa is accurate. The ability to choose the route of biopsy (transperineal vs. transrectal) is required, depending on the patients' risk and the location and size of suspicious lesions on mpMRI. Fusion image-guided prostate biopsy has the potential to allow precise management of prostate cancer, including active surveillance, radical treatment, and focal therapy.

Magnetic Resonance Imaging–guided In-bore and Magnetic Resonance Imaging-transrectal Ultrasound Fusion Targeted Prostate Biopsies: An Adjusted Comparison of Clinically Significant Prostate Cancer Detection Rate

BackgroundWith the increasing adoption of targeted prostate biopsies, it becomes important to understand the strengths and shortcomings of the techniques available for targeting suspicious lesions. ObjectiveTo compare clinically significant prostate cancer (csPCa) detection rate with magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion versus in-bore biopsy in men with abnormal multiparametric MRI (mpMRI). Design, setting, and participantsThis single-center, retrospective analysis of prospectively generated data included all men with abnormal mpMRI and fusion or in-bore biopsy between May 2017 and April 2018. Grade group (GG) 2–5 cancers were considered csPCa. Outcome measurements and statistical analysisDetection of csPCa was adjusted according to patient- and lesion-related characteristics using propensity score weighting. Secondary endpoints included the detection of clinically insignificant tumors and the rate of GG upgrade from biopsy to prostatectomy specimen. Analyses were performed at patient and lesion levels. Results and limitationsA total of 103 and 300 men were included in the in-bore and fusion cohorts, respectively. On a per-patient basis, in-bore biopsies detected a higher proportion of csPCa (61%, 63/103) than fusion plus systematic biopsies (47%, 141/300; adjusted odds ratio [OR]: 2.1, 95% confidence interval [CI]: 1.6–2.8, p<0.0001). In-bore biopsies also detected fewer (11%, 11/103) clinically insignificant cancers than fusion biopsies (18%, 53/300; OR: 0.5, 95% CI: 0.3–0.8, p=0.001). Of those who had radical prostatectomy, GG upgrade after surgery was seen in 17% (4/24) of the men in the in-bore cohort and in 27% (22/82) of the men in the fusion cohort (p=0.55). ConclusionsMRI-guided in-bore biopsies detected more clinically significant and fewer insignificant prostate cancers than MRI-TRUS fusion targeted biopsies. Further cost-utility and patient outcome analyses are needed. Patient summaryIn-bore biopsies (where the patient is on the magnetic resonance imaging [MRI] scanner itself) detected more aggressive cancers and fewer indolent cancers than fusion (where software blends MRI and ultrasound images) biopsies. These findings may help patients and physicians choose the best biopsy approach.

Multiparametric magnetic resonance imaging - Transrectal ultrasound-guided cognitive fusion biopsy of the prostate: Clinically significant cancer detection rates stratified by the Prostate Imaging and Data Reporting System version 2 assessment category.

We aimed to report the clinically significant prostate cancer (PCa) detection rate in men undergoing magnetic resonance imaging-transrectal ultrasound (MRI-TRUS)-cognitive fusion (CF) targeted biopsies stratified by the Prostate Imaging and Data Reporting System (PI-RADS) version 2 (v2) scores. With a quality assurance waiver from the IRB, we identified a cohort of men who underwent MRI-TRUS-CF and synchronous template biopsy from 2015-2017. MRI (PI-RADS v2 score, lesion size, lesion location [peripheral or transition zone (PZ/TZ)]), and CF-TRUS biopsy (operator experience, TRUS visibility, and number of biopsies) features were extracted. The primary outcome was diagnosis of clinically significant (Gleason score ≥3+4=7 or International Society of Urological Pathology (ISUP) grade group ≥2) PCa. During the study period, 131 men (with 142 PIRADS v2 score ≥3 lesions) met inclusion criteria; 98 men had previously negative template biopsy and 33 were on active surveillance for previously detected low-grade PCa. In total, 41.9% (55/131) men had clinically significant PCa - 17.6% (23/131) detected on targeted biopsy only, 8.4% (11/131) on template biopsy only, and 16.0% (21/131) on both targeted and template biopsy. Clinically significant PCa detection stratified by PI-RADS v2 scores were: 11.1% (3/27) for score 3 (indeterminate), 42.9% (24/56) for score 4 (significant cancer likely), and 35.6% (21/59) for score 5 (significant cancer very likely). Clinically significant PCa detection rates in targeted biopsies were better among PZ (41.8% [33/79]) compared to TZ (23.8% [15/63]) lesions (p=0.025) in TRUS visible lesions (p=0.033) and in the most experienced radiologists (p=0.05), with no difference by lesion size or number of additional core biopsies performed (all p&gt;0.05). Cognitive fusion MRI-TRUS-guided targeted biopsy yielded substantially lower rates of clinically significant cancer in PI-RADS v2 score 4 and 5 lesions when compared to published results using in-bore MR-guided or automated MRI-TRUS fusion guidance systems. Cancer detection was worst for TZ lesions.

Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Biopsy of the Prostate—An Update

Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Biopsy of the Prostate—An Update

Risk of Upgrading from Prostate Biopsy to Radical Prostatectomy Pathology—Does Saturation Biopsy of Index Lesion during Multiparametric Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Biopsy Help?

We sought to determine whether saturation of the index lesion during magnetic resonance imaging-transrectal ultrasound fusion guided biopsy would decrease the rate of pathological upgrading from biopsy to radical prostatectomy. We analyzed a prospectively maintained, single institution database for patients who underwent fusion and systematic biopsy followed by radical prostatectomy in 2010 to 2016. Index lesion was defined as the lesion with largest diameter on T2-weighted magnetic resonance imaging. In patients with a saturated index lesion transrectal fusion biopsy targets were obtained at 6 mm intervals along the long axis of the index lesion. In patients with a nonsaturated index lesion only 1 target was obtained from the lesion. Gleason 6, 7 and 8-10 were defined as low, intermediate and high risk, respectively. Included in the study were 208 consecutive patients, including 86 with a saturated and 122 with a nonsaturated lesion. Median patient age was 62.0 years (IQR 10.0) and median prostate specific antigen was 7.1 ng/ml (IQR 8.0). The median number of biopsy cores per index lesion was higher in the saturated lesion group (4 vs 2, p <0.001). The risk category upgrade rate from systematic only, fusion only, and combined fusion and systematic biopsy results to prostatectomy was 40.9%, 23.6% and 13.8%, respectively. The risk category upgrade from combined fusion and systematic biopsy results was lower in the saturated than in the nonsaturated lesion group (7% vs 18%, p = 0.021). There was no difference in the upgrade rate based on systematic biopsy between the 2 groups. However, fusion biopsy results were significantly less upgraded in the saturated lesion group (Gleason upgrade 20.9% vs 36.9%, p = 0.014 and risk category upgrade 14% vs 30.3%, p = 0.006). Our results demonstrate that saturation of the index lesion significantly decreases the risk of upgrading on radical prostatectomy by minimizing the impact of tumor heterogeneity.

Dynamic Contrast Enhanced Magnetic Resonance Imaging Improves Classification of Prostate Lesions: A Study of Pathological Outcomes on Targeted Prostate Biopsy.

PI-RADS™, version 2 stipulates that dynamic contrast enhanced imaging should be used to classify diffusion-weighted imaging score 3 peripheral zone lesions as PI-RADS score 3 (dynamic contrast enhanced imaging negative or nonenhancing) or 4 (dynamic contrast enhanced imaging positive or enhancing). However, to our knowledge it is unknown whether dynamic contrast enhanced imaging separates lesions into clinically meaningful pathological groups. We examined whether dynamic contrast enhanced imaging would improve the detection of clinically significant cancer. We identified patients without a prior diagnosis of prostate cancer who underwent multiparametric magnetic resonance imaging-transrectal ultrasound fusion targeted biopsy of peripheral zone lesions with adiffusion-weighted imaging score of 3 or 4. Each lesion was grouped into 1of3classifications, including group 1-diffusion-weighted imaging score 3/nonenhancing/PI-RADS score 3, group 2-diffusion-weighted imaging score 3/enhancing/PI-RADS score 4 or group 3-diffusion-weighted imaging score 4/PI-RADS score 4. We measured the rate of grade group 2 or greater pathology detected for each lesion group with subgroup analyses in patients with vs without prior negative systematic biopsy. We identified a total of 389 peripheral zone diffusion-weighted imaging score 3 or 4 lesions in 290 patients. The rate of grade group 2 or greater cancer onbiopsy for group 1, 2 and 3 lesions was 8.9%, 21% and 36.5%, respectively (p<0.03). The rate of grade group 2 or greater pathology was higher in group 2 than group 1 lesions in patients with prior negative systematic prostate biopsy(28% vs 5.0%, p <0.001) but not in those without such a biopsy (16% vs 12%, p = 0.5). Group 3 lesions had a higher rate of grade group 2 or greater cancer than group 2 lesions in the biopsy naïve subgroup (46% vs 16%, p=0.001). However, the rates were similar in patients with prior negative systematic prostate biopsy (27% vs 28%, p = 0.9). Diffusion-weighted imaging score 3 peripheral zone lesions were more likely to be clinically significant cancer (grade group 2 or greater) if they were dynamic contrast enhanced T1-weighted imaging positive. That was most apparent in patients with a prior negative systematic prostate biopsy. In such patients including a dynamic contrast enhanced sequence in multiparametric magnetic resonance imaging allowed for optimal lesion risk stratification.

Assessment of free-hand transperineal targeted prostate biopsy using multiparametric magnetic resonance imaging-transrectal ultrasound fusion in Chinese men with prior negative biopsy and elevated prostate-specific antigen

BackgroundTo evaluate the role of free-hand transperineal targeted prostate biopsy using multiparametric magnetic resonance imaging-transrectal ultrasound (mpMRI-TRUS) fusion in Chinese men with repeated biopsy.MethodsA total of 101 consecutive patients suspicious of prostate cancer (PCa) at the mpMRI scan and with prior negative biopsy and elevated PSA values were prospectively recruited at two urological centers. Suspicious areas on mpMRI were defined and graded using PI-RADS score. Targeted biopsies (TB) were performed for each suspicious lesion and followed a 12-core systematic biopsy (SB). Results of biopsy pathology and whole-gland pathology at prostatectomy were analyzed and compared between TB and SB. The risk for biopsy positivity was assessed by univariate and multivariate logistic regression analysis.ResultsFusion biopsy revealed PCa in 41 of 101 men (40.6%) and 25 (24.8%) were clinically significant. There was exact agreement between TB and SB in 74 (73.3%) men. TB diagnosed 36% more significant cancer than SB (22 vs 13 cases, P = 0.012). When TB were combined with SB, an additional 14 cases (34.1%) of mostly significant PCa (71.4%) were diagnosed (P = 0.036). TB had greater sensitivity and accuracy for significant cancer than SB in 26 men with whole-gland pathology after prostatectomy. PI-RADS score on mpMRI was the most powerful predictor of PCa and significant cancer.ConclusionsFree-hand transperineal TB guided with MRI-TRUS fusion imaging improves detection of clinical significant PCa in Chinese men with previously negative biopsy. PI-RADS score is a reliable predictor of PCa and significant cancer.

MP38-12 PROPENSITY SCORE ANALYSIS OF PATHOLOGICAL OUTCOME AT RADICAL PROSTATECTOMY FOR MAGNETIC RESONANCE IMAGING-TRANSRECTAL ULTRASOUND FUSION PROSTATE BIOPSY VERSUS UNTARGETED EXTENDED TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV1 Apr 2017MP38-12 PROPENSITY SCORE ANALYSIS OF PATHOLOGICAL OUTCOME AT RADICAL PROSTATECTOMY FOR MAGNETIC RESONANCE IMAGING-TRANSRECTAL ULTRASOUND FUSION PROSTATE BIOPSY VERSUS UNTARGETED EXTENDED TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY Hans Arora, Ahmed Elshafei, Yaw Nyame, Daniel Sun, Helen Liang, Nitin Yerram, Daniel Greene, Dominic Grimberg, Karishma Gupta, Shree Agrawal, Sudhir Isharwal, Paurush Babbar, Andrew Sun, Khaled Fareed, Michael Gong, Ryan Berglund, Eric Klein, Andrew Stephenson, Andrei Purysko, and J. Stephen Jones Hans AroraHans Arora More articles by this author , Ahmed ElshafeiAhmed Elshafei More articles by this author , Yaw NyameYaw Nyame More articles by this author , Daniel SunDaniel Sun More articles by this author , Helen LiangHelen Liang More articles by this author , Nitin YerramNitin Yerram More articles by this author , Daniel GreeneDaniel Greene More articles by this author , Dominic GrimbergDominic Grimberg More articles by this author , Karishma GuptaKarishma Gupta More articles by this author , Shree AgrawalShree Agrawal More articles by this author , Sudhir IsharwalSudhir Isharwal More articles by this author , Paurush BabbarPaurush Babbar More articles by this author , Andrew SunAndrew Sun More articles by this author , Khaled FareedKhaled Fareed More articles by this author , Michael GongMichael Gong More articles by this author , Ryan BerglundRyan Berglund More articles by this author , Eric KleinEric Klein More articles by this author , Andrew StephensonAndrew Stephenson More articles by this author , Andrei PuryskoAndrei Purysko More articles by this author , and J. Stephen JonesJ. Stephen Jones More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1165AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion-guided prostate biopsy has been shown to increase the detection of clinically significant prostate cancer (PCa) by targeting specific lesions at biopsy. Our objective was to evaluate the accuracy of MRI-TRUS fusion biopsy to determine final pathology at radical prostatectomy (RP) as compared to untargeted extended template TRUS-guided prostate biopsy. METHODS From a single institution database, 2,201 patients were identified who underwent both prostate biopsy and RP between 2006 and 2016. Propensity score matching was performed with the nearest neighbor method using R-programming version 3.3.1 and a 4:1 match ratio. A total of 101 men were identified who underwent MRI-TRUS plus standard template biopsies were subsequently matched to 404 men who underwent untargeted extended template TRUS biopsy. Matched covariates included age at diagnosis, initial prostate specific antigen (PSA), race, clinical stage, total number of cores retrieved at time of biopsy, and history of prior TRUS biopsy. Continuous variables were compared using Wilcoxon rank-sum tests and categorical variables were assessed with χ2 test. The concordance of Gleason score from biopsy to RP was assessed. RESULTS After propensity score matching, median age was 64 years (IQR 59.5-68.5), median PSA was 5.4 ng/mL (IQR 4.0-8.1), median prostate size was 48 grams (IQR 38.5-60), and median number of cores retrieved at time of biopsy was 15 (IQR 12-20). Of patients who received MRI-TRUS plus standard template biopsy, 67 of 99 (67.7%) showed concordant Gleason grading between biopsy and RP pathology, whereas 204 of 397 (51.4%) of extended template TRUS biopsy patients were concordant (p<0.01). Fewer MRI-TRUS plus standard template biopsy patients were either upgraded (26.3% versus 32.2%) or downgraded (6.1% versus 15.4%) from biopsy to RP (p<0.01). CONCLUSIONS Of men undergoing TRUS biopsy for the diagnosis of PCa, MRI-TRUS fusion plus standard template techniques have a higher concordance with final pathology at RP. Additionally, MRI-TRUS techniques demonstrated better accuracy with lower rates of upgrading and downgrading prostatectomy when compared to untargeted extended template TRUS biopsy independent of total number of cores taken. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e488-e489 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Hans Arora More articles by this author Ahmed Elshafei More articles by this author Yaw Nyame More articles by this author Daniel Sun More articles by this author Helen Liang More articles by this author Nitin Yerram More articles by this author Daniel Greene More articles by this author Dominic Grimberg More articles by this author Karishma Gupta More articles by this author Shree Agrawal More articles by this author Sudhir Isharwal More articles by this author Paurush Babbar More articles by this author Andrew Sun More articles by this author Khaled Fareed More articles by this author Michael Gong More articles by this author Ryan Berglund More articles by this author Eric Klein More articles by this author Andrew Stephenson More articles by this author Andrei Purysko More articles by this author J. 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Treatment of advanced renal cell carcinoma has progressed significantly in the past decade. Pal et al. (Duarte, CA, USA) reported a large retrospective review of advanced renal cell carcinoma in the USA. They reviewed the medical charts of 1173 patients from 318 physicians, and indicated that sunitinib and everolimus remain the most commonly used first and second targeted therapies, respectively. This article shed light on real-world practice in the USA. Cancer-related death is rare for men with biopsy-confirmed prostate cancer and a Gleason score of ≤6. This seems to be partly explained by undergrading of biopsies. Alberts et al. (Rotterdam, the Netherlands) retrospectively reviewed the biopsy specimens of 98 men with a Gleason score of ≤6 or 3 + 4 = 7. This review included 15 men who died, and had a clinical T 1/2 Gleason score of ≤6 at prevalence screening in the European Randomized study of Screening for Prostate Cancer Rotterdam cohort. They also confirmed that the International Society of Urological Pathology 2014 grading system was more accurate for prognostic assessment than the classic Gleason score. This issue includes two interesting Original Articles focusing on prostate biopsy. Shoji et al. (Tokyo, Japan) reported the accuracy of a new technique, real-time magnetic resonance imaging-transrectal ultrasound fusion transperineal target biopsy for biopsy-naïve men. They concluded that targeted biopsy is superior to conventional systemic biopsy. However, a systemic biopsy is still important, because although targeted biopsy alone diagnosed 79% of significant cancers, combined targeted + systematic biopsies diagnosed 95% of significant cancers. Kamei et al. (Tokyo, Japan) reported the prevalence and characteristics of fecal antimicrobial-resistant Escherichia coli in Japanese men undergoing transrectal prostate biopsy. Transrectal biopsy is a common procedure for the diagnosis of prostate cancer, but it has a risk of life-threatening infectious complications. Current guidelines recommend prophylactic use of fluoroquinolone. However, the results of the study revealed fecal carriage rates of fluoroquinolone-resistant E. coli and extended-spectrum b-lactamase-producing E. coli at 9.8% and 5.9%, respectively. An important article in functional urology, Ferreira et al. (Le Mans, France) reported the midterm outcomes of laparoscopic implantation of artificial urinary sphincters in women with intrinsic sphincter deficiency. They reported that 76% of patients experienced resolution, and 16% reported improvement of incontinence. The report was one of the largest series with the longest follow up for this patient population. This issue included two interesting Case Reports. The first report by Fahmy et al. (Selangor, Malaysia) described a unique ureteral substitution technique using buccal mucosa for a 64-year-old woman with a long proximal ureteral stricture after multiple bowel surgeries. Postoperative renal function was improved. The second report by Sugino et al. (Nagoya, Japan) presented a case of the successful treatment of an impacted ureteral stone in a 2-year-old girl with a single session of combined percutaneous nephrostomy and ureteroscopy using a holmium laser.

The Value of PSA Density in Combination with PI-RADS™ for the Accuracy of Prostate Cancer Prediction

Multiparametric magnetic resonance imaging has an emerging role in prostate cancer diagnostics. In addition, clinical information is a reliable predictor of significant prostate cancer. We analyzed whether the negative predictive value of multiparametric magnetic resonance imaging to rule out significant prostate cancer could be improved using clinical factors, especially prostate specific antigen density. A total of 1,040 consecutive men with suspicion of prostate cancer underwent multiparametric magnetic resonance imaging first, followed by transperineal systematic and magnetic resonance imaging-transrectal ultrasound fusion guided biopsy. Logistic regression analyses were performed to test different clinical factors as predictors of significant prostate cancer and build nomograms. To simplify these nomograms for clinical use patients were stratified into 3 prostate specific antigen density groups, including group 1-less than 0.07, group 2-0.07 to 0.15 and group 3-greater than 0.15ng/ml/ml. After stratification we calculated the negative predictive value of a PI-RADS (Prostate Imaging Reporting and Data System) Likert score of less than 3. Significant prostate cancer was defined as a Gleason score of 3 + 4 or greater. High grade prostate cancer was defined as a Gleason score of 4 + 3 or greater. Overall 451 men were diagnosed with significant prostate cancer, including 187 with a Gleason score of 4 + 3 or greater. On ROC curve analyses the predictive power of the developed nomogram for significant prostate cancer showed a higher AUC than that of PI-RADS alone (0.79 vs 0.75, p <0.001). The negative predictive value of harboring significant prostate cancer increased in men with unsuspicious magnetic resonance imaging from 79% up to 89% when prostate specific antigen density was 0.15 ng/ml/ml or less. In the repeat biopsy setting the negative predictive value of significant prostate cancer increased from 83% to 93%. The negative predictive value to harbor high grade prostate cancer increased from 92% up to 98% in the entire cohort. Using prostate specific antigen density combined with multiparametric magnetic resonance imaging improved the negative predictive value of PI-RADS scoring. By increasing the probability of ruling out significant prostate cancer approximately 20% of unnecessary biopsies could be avoided safely.