MRI-targeted Prostate Biopsy Research Articles

SC30 - Micro-ultrasound guided and MRI-targeted prostate biopsies for clinically significant prostate cancer diagnosis in the initial biopsy setting a cohort of biopsy-naive patients

SC30 - Micro-ultrasound guided and MRI-targeted prostate biopsies for clinically significant prostate cancer diagnosis in the initial biopsy setting a cohort of biopsy-naive patients

Evaluation of Fluorescent Confocal Microscopy for Intraoperative Analysis of Prostate Biopsy Cores

BackgroundDiagnosis of prostate cancer is based on histopathological evaluation, which is time-consuming. Fluorescent confocal microscopy (FCM) is a novel technique that allows rapid tissue analysis. ObjectiveTo determine if FCM could be used for real-time diagnosis of prostate cancer and evaluate concordance with traditional analysis. Design, setting, and participantsFrom January 2019 to March 2020, 182 magnetic resonance imaging–targeted prostate biopsy cores from 57 consecutive biopsy-naïve men with suspected prostate cancer were taken. These were intraoperatively stained with acridine orange for analysis using FCM (VivaScope; MAVIG, Munich, Germany) and subsequently sent for traditional haematoxylin-eosin histopathological (HEH) examination. Two expert uropathologists analysed the FCM and HEH cores blinded to the counterpart results in a single institution. Outcome measurements and statistical analysisAgreement between FCM and HEH analysis in terms of the presence of cancer was analysed at biopsy core and region of interest (ROI) levels, considering HEH as the reference test. Results and limitationsFCM allowed intraoperative assessment of prostate biopsy cores with strong histopathological evaluation agreement: Cohen’s κ for agreement was 0.81 at the biopsy core level and 0.69 for the ROI level. Positive predictive values (85% and 83.78%) and negative predictive values (95.1% and 85.71%) were high at the biopsy core and ROI levels. These initial results are encouraging, but given the single-centre and preliminary nature of the study, further confirmation is required. ConclusionsFCM allowed rapid evaluation of prostate biopsy cores. This technique is feasible and achieves rapid closure with a reliable diagnosis, parallel to the gold standard analysis. Initial results are promising but further studies are needed to validate and define the role of this technique. Patient summaryA novel microscopic technique reduces the time needed to obtain a prostate cancer diagnosis by speeding up biopsy processing. Although the initial results are promising; this development needs to be confirmed in further studies.

PT428 - Direct and marginal cost analysis of not aiming for the target in a MRI-targeted prostate biopsy pathway

PT428 - Direct and marginal cost analysis of not aiming for the target in a MRI-targeted prostate biopsy pathway

PT021 - Novices in MRI-targeted prostate biopsy benefit from structured reporting of MRI findings

The aim of this study was to investigate whether structured reports (SRs) of prostate MRI results are more suitable than non-structured reports (NSRs) for promoting the more accurate assessment of the location of a single prostate cancer lesion by novices in MRI-targeted biopsy. 50 NSRs and 50 SRs describing a single prostatic lesion were presented to 5 novices in MRI-targeted biopsy. The participants were asked to plot the tumor location in a two-dimensional prostate diagram and to answer a questionnaire on the quality of the reports. The accuracy of the plotted tumor position was evaluated with a validated 30-point scoring system that distinguished between “major” and “minor” mistakes. The overall mean score for the accuracy of the tumor plotting was significantly higher for SRs than for NSRs (26.4 vs. 20.7, p < 0.01). The mean numbers of major (1.4 vs. 0.48, p < 0.01) and minor (3.05 vs. 1.15, p < 0.01) mistakes were significantly higher for NSRs than for SRs. Compared with NSRs, SRs received significantly higher ratings for the perceived quality of the summary (4.0 vs. 2.4, p < 0.01) as well as for the overall satisfaction with the report (4.1 vs. 2.1, p < 0.01). Novices in MRI-targeted biopsy prefer structured reporting of prostate MRI as an information tool. SRs allow for a more accurate assessment of the location of single prostate cancer lesions. Therefore, structured reporting of prostate MRI may help to foster the learning process of novices in MRI-targeted biopsy.

MRI-targeted prostate biopsy: key considerations for pathologists.

We discuss the role of the pathologist for MRI-targeted prostate biopsy with a focus on specimen processing, reporting of pathological findings and quality assurance in establishing a successful MRI-targeted biopsy programme. The authors discuss the current issues relevant to pathologists regarding MRI-targeted prostate biopsy. In addition, a brief review of the recently published literature was performed using an English literature search on PubMed with a focus on original investigations related to MRI-targeted prostate biopsy. Our search terms included the following: 'prostate cancer', 'pathology', 'histology', 'reporting', 'cores', 'imaging', 'MRI' and 'mpMRI'. Prostate multiparametric magnetic resonance imaging (mp-MRI) and MRI-targeted biopsy has been shown to improve the diagnosis of clinically significant prostatic adenocarcinoma and can affect the management of patients with prostate cancer. The current active surveillance guidelines were based on data from TRUS biopsies and not MRI-targeted biopsies. MRI-targeted biopsy acquires multiple cores of tissue from one or more suspicious lesions found on mp-MRI. The way in which multiple targeted core biopsies obtained from a single image-directed region of interest are analysed and reported can potentially alter the Gleason score and tumour burden as reported on biopsy, which could undoubtedly alter patient management. Pathologists play an important role in the reporting of MRI-targeted prostate biopsies. How we report prostate cancer grade and extent on these biopsies can influence patient management. In addition, the pathologist should be involved in the quality assurance for patients undergoing MRI-targeted prostate biopsy.

Review article: MRI-targeted biopsies for prostate cancer diagnosis and management.

Transrectal ultrasound (TRUS)-guided biopsy has been the traditional biopsy route in the detection of prostate cancer. However, due to concern regarding overdetection of low-risk cancer and missed clinically significant cancers as well as risk of sepsis, alternative approaches have been explored. Transperineal template biopsy-sampling the gland every 5m to 10mm-reduces error by sampling the whole prostate but increases risk of detecting clinically insignificant cancers as well as conferring risks of side effects such as urinary retention and bleeding. There are various targeted biopsy techniques, each with different cancer detection rates, costs and learning curves. Current research focuses on refining biopsy methodology to maximize detection of significant cancers, whilst minimising invasiveness and complications. In this article, the up-to-date research data about MRI-targeted prostate biopsy were reviewed to show its utilization in prostate cancer management and diagnosis. Prostate multiparametric MRI has become an effective tool in the detection of significant cancers and an essential component of the prostate cancer diagnostic pathway incorporating MRI-guided biopsy decisions.

PD54-07 DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER THROUGH MRI FUSION-GUIDED VS. SYSTEMATIC STANDARD PROSTATE BIOPSIES

INTRODUCTION AND OBJECTIVE: Prostate biopsies are critical to diagnose prostate cancer (PCa) and to determine when treatment is appropriate. MRI-fusion biopsies have been utilized to try to improve detection rates of clinically significant prostate cancer (csPCa), but their exact value remains unclear. Our objective was to determine the unique contributions of MRI-targeted and systematic prostate biopsies, and how results may differ across institutions. METHODS: Biopsy (bx) results for patients receiving concurrent systematic and MRI-targeted prostate biopsies (UroNav system) were reviewed. The incidence was considered to be any bx positive for csPCa by either method, with csPCa defined as ≥ grade group 2. Patients were stratified as: active surveillance (AS), bx naïve, prior negative bx, or prior radiation (XRT) for PCa. Detection rates of systematic versus MRI-targeted biopsies within each institution and overall were calculated and compared utilizing McNemar’s tests. Rates between institutions were compared using Pearson’s chi square. RESULTS: Patient demographics and cancer detection rates for 457 individual biopsies are listed below. The figure details the percent of csPCa that would be missed if MRI-targeted or systematic biopsies were omitted, stratified by AS, bx naïve, or prior negative bx; rates were not calculated for prior XRT given the small number. Within each institution, there were no statistically significant differences in the ability of systematic versus MRI-targeted biopsies to detect csPCa, either overall or when stratified. Overall, the rates of csPCa detection were higher at institution B than institution A, with the largest differences in MRI targeted and in naïve biopsies. CONCLUSIONS: At both institutions, a significant number of csPCa diagnoses would have been missed if either bx modality was excluded. These data support concurrent MRI-fusion and systematic biopsies to achieve maximal detection of csPCa. Individual centers should evaluate their own data to determine optimal biopsy paradigms.Source of Funding: None

MP56-16 A NEW SCORING SYSTEM USING PROSTATE IMAGING REPORTING AND DATA SYSTEM (PI-RADS) TO DETECT SIGNIFICANT CANCER FOR MAGNETIC RESONANCE IMAGING-TARGETED PROSTATE BIOPSY

INTRODUCTION AND OBJECTIVE: Prostate Imaging Reporting and Data system (PI-RADs) is associated with significant cancer (SC) detection. Although PI-RADs≥ 3 is considered to be positive, there are many reports suggesting the significant different of the detection rates of SC between PI-RADs 3 and 4-5. In using PIRADs for MRI-targeted prostate biopsy (TgB), what kind of men have SC have been not fully examined. In this study, we examined the detective ability between PI-RADs 3/4-5 and developed a new scoring system for prediction for SC detection of TgB using PI-RADs. METHODS: Between April 2013 and April 2019, 470 men with PSA <20 ng/mL received TgB. PI-RADs ver. 2 was used and considered as positive in ≥3. TgB was performed 4 cores for a lesion and TgB was performed for each lesions with multiple positive PI-RADs. SC in this study was defined as Gleason Score ≥ 3+4 or maximum cancer length ≥ 5 mm. We assessed the association between the detection of SC and PI-RADs using multivariable regression analyses. Clinical variables examined included age, PSA, DRE finding, prostate volume (PV), TgB location (TZ/PZ), and PI-RADS score (3/4-5). We developed a new scoring system with first 300 cases using estimated value of multivariable analysis; we validated it with the latter 170 cases. Predictive accuracy and performance characteristics were assessed using the area under the receiver operating characteristic curve (AUC), respectively. RESULTS: In first 300 cases, the median age and PSA were 69 years and 7.7 ng/mL, respectively. Location of TgB was TZ/PZ in 75/225 men. PI-RADs were 3/4/5 in 65/178/57 men. SC was detected in 160 (53 %) men of TgB. In multivariable analysis, PI-RADS 4-5 (odds ratio [OR] 5.9, p<.01), the positive DRE (OR 4.4, p<.01), lower PV (< 30 mL, OR 2.6, p<.01), higher PSA (> 8.0 ng/mL, OR 2.4, p<.01) and PZ (OR 1.9, p< .01) were significantly associated with positive TgB for SC. From the results of the analysis, we assigned 1 to 3 points to each variable and developed a scoring system predicting positive TgB for SC (total of 0-8 points, as shown in Table) and AUC for detecting SC was 0.813. In validated group (170 cases) for this new scoring system, AUC for detecting SC was 0.811. CONCLUSIONS: We developed a new scoring system using PI-RADs for detecting SC by TgB and verified its validity. PIRDAS3 might not predict SC.Source of Funding: none

Complication Rates After TRUS Guided Transrectal Systematic and MRI-Targeted Prostate Biopsies in a High-Risk Region for Antibiotic Resistances.

Introduction: There is still an ongoing debate whether a transrectal ultrasound (TRUS) approach for prostate biopsies is associated with higher (infectious) complications rates compared to transperineal biopsies. This is especially of great interests in settings with elevated frequencies of multidrug resistant organisms (MDRO).Materials and Methods: Between 01/2018 and 05/2019 230 patients underwent a TRUS-guided prostate biopsy at the department of Urology at University Hospital Frankfurt. Patients were followed up within the clinical routine that was not conducted earlier than 6 weeks after the biopsy. Among 230 biopsies, 180 patients took part in the follow-up. No patients were excluded. Patients were analyzed retrospectively regarding complications, infections and underlying infectious agents or needed interventions.Results: Of all patients with follow up, 84 patients underwent a systematic biopsy (SB) and 96 a targeted biopsy (TB) after MRI of the prostate with additional SB. 74.8% of the patients were biopsy-naïve. The most frequent objective complications (classified by Clavien-Dindo) lasting longer than one day after biopsy were hematuria (17.9%, n = 32), hematospermia (13.9%, n = 25), rectal bleeding (2.8%, n = 5), and pain (2.2%, n = 4). Besides a known high MDRO prevalence in the Rhine-Main region, only one patient (0.6%) developed fever after biopsy. One patient each (0.6%) consulted a physician due to urinary retention, rectal bleeding or gross hematuria. There were no significant differences in complications seen between SB and SB + TB patients. The rate of patients who consulted a physician was significantly higher for patients with one or more prior biopsies compared to biopsy-naïve patients.Conclusion: Complications after transrectal prostate biopsies are rare and often self-limiting. Infections were seen in <1% of all patients, regardless of an elevated local prevalence of MDROs. Severe complications (Clavien-Dindo ≥ IIIa) were only seen in 3 (1.7%) of the patients. Repeated biopsy is associated with higher complication rates in general.

Developments in MRI-targeted prostate biopsy.

MRI-targeted prostate biopsy may be an attractive alternative to systematic biopsy for diagnosing clinically significant prostate cancer. In this narrative review, we discuss the new developments that have occurred in the advancement of MRI-targeted prostate biopsy, over the past 24 months. MRI-targeted biopsy offers enhanced diagnostic accuracy, when compared with the current standard of care of systematic transrectal ultrasound-guided (TRUS) biopsy, by decreasing the overall number of biopsies needed, maintaining or improving significant prostate cancer detection, and reducing the detection of clinically insignificant prostate cancer. The necessity of combining systematic prostate biopsy with MRI-targeted biopsy is still debated. The use of MRI--ultrasound fusion systems for lesion-targeting is promising for optimizing significant cancer detection, but recent evidence suggests that additional cognitive biopsy cores are still useful in detecting additional cancers. MRI-targeted biopsy in selected men with positive MRI offers a number of benefits over systematic biopsy in all men, and as such, may emerge as the new standard of care for the diagnosis of clinically significant prostate cancer.

MRI-Targeted Prostate Biopsy: What Radiologists Should Know.

Transrectal ultrasound (TRUS)-guided systematic biopsy, the current gold standard for the detection of prostate cancer, suffers from low sensitivity for clinically significant cancer. The use of diagnostic multiparametric MRI has increased the relevance of targeted biopsy techniques such as MRI-TRUS fusion biopsy and direct (in-bore) MRI-guided biopsy, which have higher detection rate for clinically significant cancer. Although primarily used in patients who remain at high clinical suspicion for prostate cancer despite a negative systematic biopsy, with the increasing use of upfront diagnostic MRI, these biopsies are expected to replace routine systematic biopsies. This pictorial essay aims to enhance our understanding of the concepts of these biopsy techniques so that they can be performed safely and provide maximum diagnostic yield.

Transperineal prostate biopsy with cognitive magnetic resonance imaging/biplanar ultrasound fusion: description of technique and early results.

To describe our technique and early results performing transperineal prostate biopsy using cognitive magnetic resonance imaging (MRI)/biplanar ultrasound fusion. Key components of this technique include use of the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD) and simultaneous transrectal ultrasound guidance in the axial and sagittal planes. In total, 95 patients (38 studied retrospectively and 57 studied prospectively) underwent a transperineal MRI-targeted prostate biopsy using the technique detailed in this manuscript. All biopsies were performed by a single urologist (MAG). Data were collected with respect to cancer detection rates, tolerability, and complications. The subset of patients who were studied prospectively was assessed for complications by telephone interviews performed at 4-6days and 25-31days following the prostate biopsy. Between February 2018 and June 2019, 95 men underwent a transperineal prostate biopsy using MRI/biplanar ultrasound fusion guidance. Patients had a total of 124 PI-RADS 3-5 lesions that were targeted for biopsy. In total, 108 (87.1%) lesions were found to harbor prostate cancer of any grade. Grade group ≥ 2 prostate cancer was found in 81 (65.3%) of targeted lesions. The detection rates for grade group ≥ 1 and grade group ≥ 2 prostate cancer rose with increasing PI-RADS score. In 65 (68.4%) cases, the patient's highest grade prostate cancer was found within an MRI target. Additionally, 12 of 55 (21.8%) patients who were found to have no or grade group 1 prostate cancer on systematic biopsy were upgraded to grade group ≥ 2 prostate cancer with MRI targeting. Only 1 (1.1%) patient received periprocedural antibiotics and no patient experienced an infectious complication. Self-limited hematuria and hematospermia were commonly reported following the procedure (75.4% and 40.4%, respectively) and only 1 (1.1%) patient developed urinary retention. We demonstrate the safety and feasibility of performing transperineal prostate biopsy using cognitive MRI/biplanar ultrasound fusion guidance. The described technique affords the safety benefits of the transperineal approach as well as obviates the need for a formal fusion platform. Additionally, this method can conveniently be performed under local anesthesia with acceptable tolerability.

Evaluation of MSKCC Preprostatectomy nomogram in men who undergo MRI-targeted prostate biopsy prior to radical prostatectomy

IntroductionThe Memorial Sloan Kettering Cancer Center (MSKCC) Preprostatectomy nomogram is a widely used resource that integrates clinical factors to predict the likelihood of adverse pathology at radical prostatectomy. Adoption of magnetic resonance imaging targeted biopsy (TB) permits optimized detection of clinically-significant cancer over systematic biopsy (SB) alone. We aim to evaluate the prognostic utility of the MSKCC Preprostatectomy nomogram with TB pathology results. MethodsMen who underwent SB and magnetic resonance imaging TB who later underwent radical prostatectomy at our institution were included. Patient information was entered into the MSKCC Preprostatectomy nomogram using 5 biopsy reporting schemes with TB reported by both individual core (IC) and aggregate group (AG) methods. The likelihood of extraprostatic extension, seminal vesicle invasion, and lymph node involvement as predicted by the nomogram for each biopsy reporting schema were compared to radical prostatectomy pathology. ResultsWe identified 63 men from January 2014 to November 2017. On receiver operating characteristic analysis, IC-TB, AG-TB, SB plus IC-TB, and SB plus AG-TB exhibited similar, if not improved, area under the curve compared to SB alone in predicting extraprostatic extension (0.671, 0.674, 0.658, and 0.6613 vs. 0.6085). This was similarly observed for seminal vesicle invasion prediction using SB plus IC-TB compared to SB alone (0.727 vs. 0.733). For lymph node involvement, superior but nonsignificant area under the curve was observed for AG-TB (0.647) compared to IC-TB (0.571) and SB alone (0.524) ConclusionsUsing TB pathology results either alone or combined with SB pathology results as input to the MSKCC Preprostatectomy nomogram appears comparable for prognosticating adverse pathology on radical prostatectomy compared to SB alone, but robust validation is warranted prior to adoption into clinical practice.

Initial experience with a novel method for cognitive transperineal magnetic resonance imaging-targeted prostate biopsy.

A cognitive magnetic resonance imaging (MRI)-targeted prostate biopsy conducted by an experienced clinician enhances the detection rate of (high-grade) prostate cancer; however, this method is less successful in the hands of inexperienced surgeons. Therefore, an alternative method of conducting a cognitive MRI-targeted biopsy that can be successfully performed by the inexperienced clinicians should be developed. Ninety-six males suspected of prostate cancer were analyzed using systematic biopsy and cognitive MRI-targeted biopsy based on our novel three-dimensional matrix positioning method. Typically, the core principle of the latter procedure was to put the MRI and ultrasound images into the same virtual coordinate system. Afterward, the targeted biopsy was transformed to target a coordinate for the suspected lesion in the MRI. Subsequently, patients were assessed for the presence/absence of prostate cancer or high-grade prostate cancer. According to our results, the overall detection rate of prostate cancer was 70.8% (68/96), and the detection rate of high-grade prostate cancer was 56.3% (54/96). Specifically, the detection rate of prostate cancer by systematic biopsy was 54.2% (52/96) and that by targeted biopsy was 59.4% (57/96; P = 0.560). Clearly, the combined application of targeted biopsy could remarkably increase the detection rates of prostate cancer (P = 0.025) and high-grade prostate cancer (P = 0.009). Taken together, the findings of this study suggest that the combination of systematic biopsy with our three-dimensional matrix positioning-driven cognitive-targeted biopsy is superior to systematic biopsy in detecting prostate cancer and high-grade prostate cancer.

Patient-reported pain, discomfort, and anxiety during magnetic resonance imaging-targeted prostate biopsy.

The addition of targeted prostate biopsy to systemic biopsy impacts patient experience. We examined patient-reported pain, discomfort, anxiety, and tolerability among men undergoing magnetic resonance imaging (MRI)-targeted prostate biopsy in addition to transrectal ultrasound-guided systematic biopsy compared to those undergoing systematic biopsy alone. All patients underwent transrectal systematic 14-core biopsies. Patients with regions of interest on MRI underwent additional targeted biopsies. All patients received equivalent periprostatic nerve block. Four single-item, standard, 11-point numerical rating scales evaluating pain, discomfort, anxiety, and tolerability were completed immediately after biopsy. Differences in means were compared using t-tests. Correlation between rated domains was tested using Spearman's correlation coefficient. Of 273 consecutive patients, 195 (71%) underwent targeted biopsy and 188 (69%) had undergone prior biopsy. In all men, the median score for pain and tolerability was 3, while the median score for discomfort and anxiety was 4. Pain was rated at 7 or above by 15% of patients. Moderate correlation between pain, discomfort, anxiety, and tolerability of repeat biopsy was observed (Spearman's ρ between 0.48 and 0.76). Compared to patients undergoing systematic biopsy alone, men who received both targeted and systematic biopsies reported higher anxiety scores (difference 1.2; 95% confidence interval [CI] 0.4-2.0; p=0.004) and discomfort (difference 1.0; 95% CI 0.3-1.7; p<0.001). Patients undergoing targeted and systematic biopsies report more discomfort and anxiety than patients undergoing systematic biopsies alone. Absolute differences are small, and patients are willing to undergo repeat biopsy if advised. Interventions to reduce biopsy-related anxiety are needed.

Is There Still a Need for Repeated Systematic Biopsies in Patients with Previous Negative Biopsies in the Era of Magnetic Resonance Imaging-targeted Biopsies of the Prostate?

BackgroundThe role of targeted prostate biopsies (TBs) in patients with cancer suspicious lesions on multiparametric magnetic resonance imaging (mpMRI) following negative systematic biopsies (SBs) is undebated. However, whether they should be combined with repeated SBs remains unclear. ObjectiveTo evaluate the value of repeated SBs in addition to TBs in patients with a prior negative SB and a persistent suspicion of prostate cancer (PCa). Design, setting, and participantsA prospective study as part of a multicenter randomized controlled trial conducted between 2014 and 2017, including 665 men with a prior negative SB and a persistent suspicion of PCa (suspicious digital rectal examination and/or prostate-specific antigen >4.0ng/ml). InterventionAll patients underwent 3T mpMRI according to Prostate Imaging Reporting and Data System (PI-RADS) v2. Patients with PI-RADS ≥3 were randomized 1:1:1 for three TB techniques: MRI-TRUS fusion TB (FUS-TB), cognitive registration fusion TB (COG-TB), or in-bore MRI TB. FUS-TB and COG-TB were combined with repeated SBs. Outcome measurements and statistical analysisClinically significant prostate cancer (csPCa) was defined as Gleason ≥3+4. Differences in detection rates of csPCa, clinically insignificant PCa (cisPCa), and overall PCa between TBs (FUS-TB and COG-TB) and repeated SBs were compared using McNemar's test. Results and limitationsIn the 152 patients who underwent both TB and SB, PCa was detected by TB in 47% and by SB in 32% (p<0.001, 95% confidence interval [CI]: 6.0–22%). TB detected significantly more csPCa than SB (32% vs 16%; p<0.001, 95% CI: 11–25%). Clinically significant PCa was missed by TB in 1.3% (2/152). Combining SB and TB resulted in detection rate differences of 6.0% for PCa, 5.0% for cisPCa, and 1.0% for csPCa compared with TB alone. ConclusionsIn case of a persistent suspicion of PCa following a negative SB, TB detected significantly more csPCa cases than SB. The additional value of SB was limited, and only 1.3% of csPCa would have been missed when SB had been omitted. Patient summaryWe evaluated the role of systematic biopsies and magnetic resonance imaging (MRI)-targeted biopsies for the diagnosis of prostate cancer in patients with prior negative systematic biopsies. MRI-targeted biopsies perform better in detecting prostate cancer in these patients. The value of repeated systematic biopsies is limited.

Closing the Loop on the Role of Multiparametric Magnetic Resonance Imaging–Targeted Prostate Biopsy

Closing the Loop on the Role of Multiparametric Magnetic Resonance Imaging–Targeted Prostate Biopsy

Multiparametric MRI fusion-guided prostate biopsy in biopsy naive patients: Preliminary results from 80 patients.

The aim of this prospective study was to evaluate the early results of transrectal prostate biopsies performed under the guidance of multiparametric prostate magnetic resonance imaging (mpMRI) in biopsy naive patients. Biopsy naive patients who had prostate-specific antigen level 4-10 ng/mL and/or abnormal digital rectal examination findings and provided informed consent were examined using mpMRI. The study included 80 patients with an MRI-defined lesion with a Prostate Imaging and Reporting and Data System (PIRADS) score of ≥3. All mpMRIs were reported by the same uro-radiologist according to PIRADS version 2. An MRI-targeted biopsy was performed by an ultrasonography system with rigid fusion registration software. The first two to five core biopsies per MRI-defined lesions were obtained, and then a standard random 12-core biopsy was performed. Transrectal biopsies were performed under local anesthesia or sedoanalgesia. Of the 80 patients, 29 (36.3%) were found to have cancer using the conventional 12-core biopsy, but only 20 (25%) were found to have prostate cancer using the MRI-targeted prostate biopsy. Combining the two biopsy methods (conventional+MRI-targeted), cancer detection rate increased to 43.8% (35/80 patients). The cancer detection rate using the combined method was statistically higher than that using the conventional biopsy method (p=0.03). Using the conventional biopsy method, 960 core biopsies were collected from 80 patients. Of the 960 core biopsies, 111 (11.6%) were found to be cancer. Further, 101 suspected lesions were detected using mpMRI in 80 patients. In addition, 397 core biopsies were obtained from these lesions. Of the 397 core biopsies, 62 (15.6%) were reported as prostate cancer. The core positivity rate of MR-targeted biopsy was statistically higher than that of conventional biopsy (p=0.04). The preliminary results of MRI-targeted prostate biopsy combined with conventional biopsy suggested that the combined biopsy method was crucial in prostate cancer diagnosis especially in patients with prostate cancer suspicion and no biopsy history. However, larger sample prospective studies are needed to validate the effectiveness of MRI-targeted biopsy and combined biopsy methods.

Validation of MSKCC pre-prostatectomy nomogram in men who undergo MRI-targeted prostate biopsy prior to radical prostatectomy.

14 Background: The Memorial Sloan Kettering Cancer Center (MSKCC) Pre-Prostatectomy nomogram is a widely used resource using clinical factors to predict the likelihood of adverse pathology at radical prostatectomy. The increasing adoption of magnetic resonance imaging (MRI) and MRI-targeted biopsy (TB) permits optimized detection of clinically-significant cancer over systematic biopsy sampling alone. We aim to validate the prognostic utility of the MSKCC Pre-Prostatectomy nomogram with TB pathology results. Methods: Men who underwent systematic extended-sextant prostate biopsy (SB) followed by MRI TB who later underwent radical prostatectomy at our institution were included. Patient information was entered into the MSKCC Pre-Prostatectomy nomogram using five biopsy reporting schemes (SB alone, TB alone reported each of two ways (individual core (IC) technique or aggregate cores (AG) technique combining cores from a single MRI targeted lesion), and SB with TB combined with TB reported by both IC and AG methods. The likelihood of extracapsular extension (EPE), lymph node involvement (LNI), and seminal vesicle invasion (SVI) as predicted by the nomogram for each biopsy reporting schema were compared to radical prostatectomy pathology. Results: We identified 63 men from January 2014 to November 2017. On ROC analysis, IC-TB, AG-TB, SB plus IC-TB, and SB plus AG-TB exhibited similar, if not improved, AUC compared to SB alone in predicting EPE (0.671, 0.674, 0.658, and 0.6613 versus 0.6085). For LNI, superior AUC was observed for AG-TB (0.647) compared to IC-TB (0.571) and SB alone (0.524) Equivocal SVI prediction was observed for SB plus IC-TB compared to SB alone (0.727 versus 0.733). Conclusions: Using TB pathology results either alone or combined with SB pathology results for the MSKCC Pre-Prostatectomy nomogram appears comparable, if not improved, in prognosticating adverse pathologic features on radical prostatectomy compared to using SB core data alone from which the nomogram was developed.

How Would MRI-Targeted Prostate Biopsy Alter Radiation Therapy Approaches in Treating Prostate Cancer?

Magnetic resonance (MR)/ultrasound fusion-targeted prostate biopsy has been shown to improve detection of clinically-significant prostate cancer over systematic biopsy sampling. The effects of targeted biopsy on radiation therapy recommendations are not well understood. We aim to determine if targeted biopsy would lead to increased recommendations of aggressive radiotherapy treatments for higher risk prostate cancer compared to standard biopsy results. This is a retrospective review of prospectively gathered clinicopathologic data of 533 men who underwent both standard and targeted prostate biopsy from 2014-2017. Three patient cohorts were established: (1) biopsy naïve (80/533), (2) active surveillance (185/533), and (3) prior negative biopsy (268/533). Cancer risk category criteria were established with recommended radiotherapy treatment for each (Table 1). Variation of risk classification due to biopsy method for all patients and within each cohort were analyzed using either a chi-squared statistic or Fisher’s Exact test. McNemar’s pairwise analyses were performed for all risk categories between targeted and standard biopsy to assess the effects of targeted biopsy on high-risk cancer identification and subsequent radiotherapy recommendations. Distribution of patients within cancer risk categories varied due to targeted and standard biopsies among all patients (p<0.0001), in cohort 2 (p=0.0005), and in cohort 3 (p<0.0001). Further, among all patients, targeted biopsy increased cancer risk classification and, correspondingly, would likely result in more aggressive radiotherapy recommendations: Low-Risk to Intermediate-Risk (Gleason 4+3) (29/343, p<0.0001), Low-Risk to High-Risk (31/353, p<0.0001), and Intermediate-Risk (Gleason 3+4) to Intermediate-Risk (Gleason 4+3) (6/63, p=0.01). Among men with prostate cancer, the addition of targeted biopsy commonly led to reclassification to a higher risk group, which is likely accompanied by more aggressive radiotherapy treatment recommendations when compared with systematic biopsy sampling findings alone. Future prospective studies are needed to validate the degree of altered clinical recommendations regarding radiotherapy approaches due to targeted prostate biopsy.Abstract SU_26_2254; Table 1Prostate cancer risk category classification criteria and associated radiotherapy recommendations.Cancer Classification CriteriaTreatmentLow Risk CA- Gleason ≤ 6 - and PSA < 10 ng/mL - and ≤T2b by DRE- Fractionated EBRT - SBRT - Brachytherapy without EBRTFavorable Intermediate Risk CA- Gleason 7 (3+4) - or PSA 10-20 ng/mL - or T2c by DRE- Same as Low Risk CAUnfavorable Intermediate Risk CA- Gleason 7 (4+3) - or PSA 10-20 ng/mL - or T2c by DRE- Fractionated EBRT - SBRT - Brachytherapy with EBRT - ADTHigh Risk CA- Gleason ≥8 - or PSA ≥ 20 ng/mL - or ≥ T3a by DRE- Fractionated EBRT - EBRT with brachytherapy boost - ADT Open table in a new tab