Negative Transrectal Ultrasound Research Articles

This Month in Adult Urology

This Month in Adult Urology

A Nationwide Analysis of Risk of Prostate Cancer Diagnosis and Mortality following an Initial Negative Transrectal Ultrasound Biopsy with Long-Term Followup.

Magnetic resonance imaging (MRI) targeted prostate biopsy has been shown to find many high-grade prostate cancers in men with concurrent negative transrectal ultrasound (TRUS) systematic biopsy. The oncologic risk of such tumors can be explored by looking at long-term outcomes of men with negative TRUS biopsy followed without MRI. The aim was to analyze the mortality after initial and second negative TRUS biopsy. All men who underwent initial TRUS biopsies between January 1, 1995 and December 31, 2016 in Denmark were included. A total of 37,214 men had a negative initial TRUS biopsy and 6,389 underwent a re-biopsy. Risk of cause-specific mortality was analyzed with competing risks. Diagnosis of Gleason score ≥7 prostate cancer following negative biopsies was analyzed with multivariable logistic regression including time to re-biopsy, prostate specific antigen (PSA), age and digital rectal examination. The 15-year prostate cancer-specific mortality was 1.9% (95% CI: 1.7-2.1). Prostate cancer-specific mortality was 1.3% (95% CI: 0.9-1.6) and 4.6% (95% CI: 3.4-5.8) for men with PSA <10 and >20 ng/ml, respectively. Of the TRUS re-biopsies 12% were Gleason score ≥7 and risk of Gleason score ≥7 increased with longer time to re-biopsy (p <0.001). Mortality after re-biopsy was similar to after initial biopsy. Men with negative TRUS biopsies have a very low prostate cancer-specific mortality, especially with PSA <10 ng/ml. This raises serious questions about the routine use of MRI targeting for initial prostate biopsy and suggests that MRI targeting should only be recommended for men with PSA >10 ng/ml after negative biopsy.

The value of magnetic resonance imaging-ultrasound fusion targeted biopsies for clinical decision-making among patients with previously negative transrectal ultrasound biopsy and persistent prostate-specific antigen elevation.

Targeted biopsy approaches have been shown to increase the detection of clinically significant prostate cancer (csPCa) within index prostate lesions. We report our initial experience with magnetic resonance imaging-ultrasound fusion biopsies (MRI-TB) in a population of men who had a previously negative transrectal ultrasound (TRUS) biopsy, persistent prostate-specific antigen (PSA) elevation, and ongoing suspicion of PCa. Patients were followed prospectively to assess for changes in clinical management following targeted biopsy. We prospectively followed the first 122 patients undergoing MRI-TB at our institution. All men had clinical suspicion of PCa, prior negative TRUS biopsies, and persistent PSA elevation. A total of 177 index lesions were identified on multiparametric MRI and reviewed using the Prostate Imaging Reporting and Data System (PI-RADS) v2 scoring system. Lesions classified as PI-RADS ≥3 received targeted biopsy. Biopsy-naive patients and those on active surveillance were excluded. The primary outcome was detection rate of csPCa, defined as International Society of Urological Pathology (ISUP) Grade Group (GG) ≥2. Multivariate analysis was used to determine predictors of csPCa on fusion biopsy. Prior to fusion biopsy, patients had a mean of 17.9±8.6 negative core biopsies per patient and a median PSA of 9.5 (standard deviation [SD] 6.2) ng/nl. MRI-TB resulted in diagnosis of csPCa in 42/122 (34.4%) patients. Clinically significant PCa was found in eight (13.1%), 14 (21.9%), and 25 (48.1%) of PI-RADS 3, 4, and 5 lesions, respectively. The location of csPCa was within the peripheral zone (55.3%), transitional zone (40.4%), and central zone (8.5%). Clinical outcomes of patients with newly diagnosed csPCa show 4.8%, 57.1%, and 38.1% receiving active surveillance, radiation treatment, and radical prostatectomy, respectively. Predictors for csPCa were presence of PI-RADS 5 lesions, age, length of time from MRI to biopsy, and smaller prostate volumes. MRI-TB yields high detection rates for csPCa in men with elusive PSA elevation and frequently guides a change in clinical management. Clinical decision-making based on MRI findings and PI-RADS lesion scores are best informed by an understanding of institutional reporting patterns.

Efficacy of 3T Multiparametric MR Imaging followed by 3T in-Bore MR-Guided Biopsy for Detection of Clinically Significant Prostate Cancer Based on PIRADSv2.1 Score

PurposeTo evaluate the diagnostic yield of 3T in-Bore magnetic resonance-guided biopsy (3T IB-MRGB) for detection of clinically significant prostate cancer (csPCa), based on assessment using the Prostate Imaging Reporting and Data System version 2.1 (PIRADSv2.1). Materials and MethodsThis single-center study examined individuals who underwent 3T multiparametric prostate magnetic resonance (MR) imaging and subsequent 3T IB-MRGB. The final study cohort included 379 men (with 475 targets) divided into 3 subcohorts: biopsy-naïve men (n = 123), individuals with a history of negative trans-rectal-ultrasonography (TRUS) biopsy results (n = 106), and men with low-grade PCa under active surveillance (n = 150). csPCa was defined as having a Gleason score (GS) ≥3+4. Results3T IB-MRGB detected PCa and csPCa in 69.1% (262 of 379) and 50.3% (193 of 379) of patients, respectively. The PCa and csPCa detection rates per target were 64.2% (305 of 475) and 43.8% (208 of 475), respectively. The rate of urosepsis, treated with intravenous antibiotics, was 1% (4 patients). In TRUS biopsy negative results and biopsy-naïve subcohorts, csPCa was found in 36.8% (39 of 106) and 52.8% (65 of 123), respectively. In 50.7% (76 of 150) of the active surveillance subcohort, 3T IB-MRGB upgraded the GS assigned in prior TRUS biopsies. Positive predictive values of PIRADSv2.1 categories 3, 4, and 5 for csPCa detection were 24.8%, 44.4%, and 67.1%, respectively. Higher PIRADSv2.1 categories were significantly associated with PCa (odds ratio [OR], 3.97; 95% confidence interval [CI], 2.98–5.28) and csPCa (OR, 1.41; 95% CI, 1.03–1.94) detection. Of 137 PIRADSv2 category 3 lesions, 28 were downgraded to PIRADSv2.1 category 2, in which there were no occurrences of csPCa in histology. ConclusionsUse of 3T IB-MRGB resulted in detection of csPCa in 50.9% of individuals. 3T IB-MRGB has a high diagnostic yield in individuals with negative TRUS biopsy results and those under active surveillance. The PIRADSv2.1 category is a strong predictor of PCa and csPCa detection.

PD48-02 DECISION-ANALYTIC MODELING STUDY OF THE PRECISION TRIAL: DOES PRE-BIOPSY MRI DO MORE GOOD THAN HARM?

You have accessJournal of UrologyProstate Cancer: Detection & Screening V (PD48)1 Apr 2020PD48-02 DECISION-ANALYTIC MODELING STUDY OF THE PRECISION TRIAL: DOES PRE-BIOPSY MRI DO MORE GOOD THAN HARM? Andrew Vickers* and Sigrid Carlsson Andrew Vickers*Andrew Vickers* More articles by this author and Sigrid CarlssonSigrid Carlsson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000942.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Several recent studies, including the randomized PRECISION trial, have investigated whether men with elevated prostate-specific antigen (PSA) levels should undergo magnetic resonance imaging (MRI) before prostate biopsy, with targeted biopsy performed if MRI is positive and no biopsy for MRI negative patients. The finding that MRI reduces the number of low-grade and increases the number of high-grade cancers has been interpreted as supporting MRI. However, a technique that overgraded tumors would report similar findings. Study findings at the group level need to be complemented by modeling studies of individual patient counterfactuals. For instance, a patient who would have been grade Grade Group (GG) 1 by regular transrectal ultrasound (TRUS) biopsy but GG2 by MRI would only benefit if confirmatory biopsy after TRUS would show GG2 (hence MRI would avoid an additional biopsy) or if delayed treatment affected chance of cure. If neither are true, the patient would be harmed by curative treatment resulting from the increased grade. METHODS: We used the PRECISION trial results to create different scenarios for individual patient counterfactuals, varying the proportion of MRI-detected high-grade cancers that were reclassified from low-grade vs. benign TRUS biopsy. We assumed that only patients diagnosed with GG2+ would be treated curatively with active surveillance for GG1. We considered treatment to constitute high harm, active surveillance to be moderate harm and additional biopsy to constitute minor harm. As there is evidence that long-term rates of prostate cancer death are very low for both patients with negative TRUS biopsy and those with GG1 followed on active surveillance, delayed treatment was considered to be a moderate harm. We tested a range of scenarios for degree of harm. RESULTS: In most scenarios, MRI was associated with very low levels of net benefit that were highly dependent on assuming that the higher rates of GG2+ disease on MRI resulted from reclassification from benign disease on TRUS. In the base case, the highest net benefit for MRI across scenarios was the equivalent of 50 MRIs to prevent one overdiagnosis of GG1. MRI had was harmful in many scenarios. MRI had important benefit only under the scenario where MRI and TRUS tumors were, grade for grade, of similar oncologic risk, a position not supported by best evidence. CONCLUSIONS: Decision-analytic modelling of how MRI impacts the treatment of individual patients does not support the routine use of MRI before diagnostic biopsy, with biopsy only targeted to suspicious lesions and no biopsy for negative MRI. Source of Funding: This work was supported in part by the National Institutes of Health/National Cancer Institute (NIH/NCI) with a Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center [P30 CA008748], and a SPORE grant in Prostate Cancer [P50-CA92629]. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e993-e994 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Vickers* More articles by this author Sigrid Carlsson More articles by this author Expand All Advertisement PDF downloadLoading ...

Consecutive transperineal prostatic template biopsies employing cognitive and systematic approach: a single center study

Introduction The role of transperineal template biopsy for prostate cancer diagnosis is well established. Pre-biopsy multiparametric magnetic resonance imaging (MRI) is used in most centers for planning of prostate biopsies and staging. Cognitive and software fusion techniques are increasingly getting popular. Methods We retrospectively reviewed patients who underwent transperineal template biopsies from January 2016 till December 2018. This included patients on active surveillance, previous negative transrectal ultrasonography biopsies with persistently raised prostate-specific antigen/abnormal prostate on digital rectal examination and de-novo template biopsies. Two specialist uro-radiologists reported all the scans and the biopsies were performed by one experienced urologist. The cognitive biopsies were performed for PIRADS 3–5 lesions on MRI. Total of 330 patients underwent transperineal template biopsies and cognitive target biopsies were carried out in 75 patients who were included in the study. We evaluated the results as positive/negative cognitive biopsies and also according to the PIRAD scoring. Only the patients with prostate cancer on template biopsy histology were included. Results Fifty-seven (76%) of the cognitive biopsies were positive out of total 75. PIRAD Score P ositive N egative PIRAD 3 8 (53.33%) 7 PIRAD 4 36 (83.72%) 7 PIRAD 5 13 (76.47%) 4 Conclusions Combined cognitive and systematic biopsies have excellent diagnostic rate especially for PIRAD 4–5 MRI areas.

Which scores need a core? An evaluation of MR-targeted biopsy yield by PIRADS score across different biopsy indications.

Magnetic resonance imaging is being widely adopted in the clinical management of prostate cancer. The correlation of the Prostate Imaging Reporting and Data System (PIRADS) to the presence of cancer has been established but studies have primarily evaluated this in a single clinical setting. This study aims to characterize the correlation of PIRADS score to the diagnosis of cancer on fusion biopsy among men who are undergoing primary biopsy, those who have had a previous negative biopsy or men on active surveillance. A consecutive sample of men undergoing US-MR biopsy at a single academic institution from 2014 to 2017 were included in this retrospective study. Men were stratified into groups according to their clinical history: biopsy-naïve, previous negative transrectal ultrasound (TRUS) biopsy or on active surveillance. The correlation of PIRADS score to the diagnosis of any and clinically significant cancer (Gleason score ≥ 3 + 4) was determined. A total of 255 patients with 365 discrete lesions were analyzed. PIRADS score 1-2, 3, 4 and 5 yielded any prostate cancer in 7.7, 29.7, 42.3 and 82.4% of the cases, respectively, across all indications while clinically significant cancer was found in 0, 8.9, 21.4 and 62.7%, respectively. The area under the receiver operative curves for the diagnosis of any and significant cancer was 0.69 (95%CI: 0.64-0.74) and 0.74 (95%CI: 0.69-0.79) respectively. Men who have had a previous negative biopsy had lower detection rates for any prostate cancer for PIRADS 3 and 4 lesions compared to those that were biopsy-naïve or on active surveillance. Cancer detection rates are significantly associated with PIRADS score. Biopsy yields differ across biopsy indications which should be considered when selecting a PIRADS score threshold for biopsy. Biopsy of PIRADS 3 lesions could potentially be avoided in men who have previously undergone a negative TRUS biopsy.

Incremental value of 68-gallium-prostate-specific membrane antigen positron emission tomography/computed tomography in patients with abnormal prostate-specific antigen and benign transrectal ultrasound biopsy.

Introduction:Bladder outlet obstruction due to prostate enlargement is a common health problem in male and frequently investigated with prostate-specific antigen (PSA) and transrectal ultrasound (TRUS). TRUS-guided biopsy is critical to differentiate benign prostatic hyperplasia (BPH) or prostate cancer (PCa) even though it has been associated with false negative with reported 3%–16% incidence of PCa in BPH specimens. Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT), a targeted molecular imaging for PCa, has showed promising results in recurrence and staging. We analyzed its role in patients with abnormal PSA and benign TRUS biopsy.Material and Methods:Of 558 68Ga-PSMA PET/CT performed from July 2014 to February 2017, we found six patients with abnormal PSA (range 8.2–24.2 ng/ml, median: 13.3 ng/ml) with benign 12 cores TRUS biopsy as indication. These cases were reanalyzed in detail. Spearman's rank test was used entire correlation using SPSS version 21.Results:68Ga-PSMA PET/CT showed mild diffuse tracer uptake in prostate in all patients with no focality and maximum standard uptake value normalized to body weight (SUVmax) range was 3.2-5.8 (median: 3.9). Two patients with PSA <10 ng/ml had normal 68Ga-PSMA PET/CT and underwent medical management. In other four patients with PSA >10 ng/ml, two showed metastatic disease in pelvic lymph node in both and in lung in one; hence, 68Ga-PSMA PET/CT changed these patients' management. Spearman's rank test showed no correlation with baseline PSA and SUVmax of prostate (rs −0.0287, P = 0.9571) while strong positive correlation was seen with baseline PSA and 68Ga-PSMA PET/CT scan positivity for extraprostatic disease (rs = 0.828, P = 0.042).Conclusions:68Ga-PSMA whole-body PET/CT can provide useful incremental information in patient with high PSA and negative TRUS biopsy and has a potential to guide management in this subgroup of PCa patients.

Abbreviated Biparametric Prostate MR Imaging in Men with Elevated Prostate-specific Antigen.

Purpose To determine the diagnostic accuracy for clinically significant prostate cancer achieved with abbreviated biparametric prostate magnetic resonance (MR) imaging in comparison with full multiparametric contrast material-enhanced prostate MR imaging in men with elevated prostate-specific antigen (PSA) and negative transrectal ultrasonography (US)-guided biopsy findings; to determine the significant cancer detection rate of biparametric versus full multiparametric contrast-enhanced MR imaging and between-reader agreement for interpretation of biparametric MR imaging. Materials and Methods In this institutional review board-approved retrospective review of prospectively acquired data, men with PSA greater than or equal to 3 ng/mL after negative transrectal US-guided biopsy findings underwent state-of-the-art, full multiparametric contrast-enhanced MR imaging at 3.0-T including high-spatial-resolution structural imaging in several planes, diffusion-weighted imaging at 0, 800, 1000, and 1400 mm2/sec, and dynamic contrast-enhanced MR imaging, obtained without endorectal coil within 34 minutes 19 seconds. One of four radiologists with different levels of expertise (1-9 years) first reviewed only a fraction of the full multiparametric contrast-enhanced MR images, consisting of single-plane (axial) structural imaging (T2-weighted turbo spin-echo and diffusion-weighted imaging), acquired within 8 minutes 45 seconds (referred to as biparametric MR imaging), and established a diagnosis according to the Prostate Imaging Reporting and Data System (PI-RADS) version 2; only thereafter, the remaining full multiparametric contrast-enhanced MR images were read. Men with PI-RADS categories 3-5 underwent MR-guided targeted biopsy. Men with PI-RADS categories 1-2 remained in urologic follow-up for at least 2 years, with rebiopsy (transrectal US-guided or transperineal saturation) where appropriate. McNemar test was used to compare diagnostic accuracies. To investigate between-reader agreement, biparametric MR images of 100 patients were read independently by all three radiologists. Results A total of 542 men, aged 64.8 years ± 8.2 (median PSA, 7 ng/mL), were included. Biparametric MR imaging helped detect clinically significant prostate cancer in 138 men. Full multiparametric contrast-enhanced MR imaging allowed detection of one additional clinically significant prostate cancer (a stage pT2a, intermediate-risk cancer with a Gleason score of 3+4) and caused 11 additional false-positive diagnoses. Diagnostic accuracy for detection of clinically significant cancer of biparametric MR imaging (89.1%, 483 of 542) was similar to that of full multiparametric contrast-enhanced MR imaging (87.2%, 473 of 542). Between-reader agreement of biparametric MR imaging interpretation was substantial (κ = 0.81). Conclusion Biparametric MR imaging allows detection of clinically significant prostate cancer missed by transrectal US-guided biopsy. Biparametric prostate MR imaging takes less than 9 minutes examination time, works without contrast agent injection, and offers a diagnostic accuracy and cancer detection rate that are equivalent to those of conventional full multiparametric contrast-enhanced MR imaging protocols. © RSNA, 2017.

Pathologic correlation of transperineal in-bore 3-Tesla magnetic resonance imaging-guided prostate biopsy samples with radical prostatectomy specimen.

To determine the accuracy of in-bore transperineal 3-Tesla (T) magnetic resonance (MR) imaging-guided prostate biopsies for predicting final Gleason grades in patients who subsequently underwent radical prostatectomy (RP). A retrospective review of men who underwent transperineal MR imaging-guided prostate biopsy (tpMRGB) with subsequent radical prostatectomy within 1 year was conducted from 2010 to 2015. All patients underwent a baseline 3-T multiparametric MRI (mpMRI) with endorectal coil and were selected for biopsy based on MR findings of a suspicious prostate lesion and high degree of clinical suspicion for cancer. Spearman correlation was performed to assess concordance between tpMRGB and final RP pathology among patients with and without previous transrectal ultrasound (TRUS)-guided biopsies. A total of 24 men met all eligibility requirements, with a median age of 65 years (interquartile range [IQR] 11.7). The median time from biopsy to RP was 85 days (IQR 50.5). Final pathology revealed Gleason 3+4=7 in 12 patients, 4+3=7 in 10 patients, and 4+4=8 in 2 patients. A strong correlation (ρ: +0.75, p<0.001) between tpMRGB and RP results was observed, with Gleason scores concordant in 17 cases (71%). 16 of the 24 patients underwent prior TRUS biopsies. Subsequent tpMRGB revealed Gleason upgrading in 88% of cases, which was concordant with RP Gleason scores in 69% of cases (ρ: +0.75, p<0.001). Final Gleason scores diagnosed by tpMRGB at 3-T correlate strongly with final RP surgical pathology. This may facilitate prostate cancer diagnosis, particularly in patients with negative or low-grade TRUS biopsy results in whom clinically significant cancer is suspected or detected on mpMRI.

MRI-directed cognitive fusion-guided biopsy of the anterior prostate tumors.

We aimed to evaluate the efficacy of magnetic resonance imaging (MRI)-directed cognitive fusion transrectal ultrasonography (TRUS)-guided anterior prostate biopsy for diagnosis of anterior prostate tumors and to illustrate this technique. A total of 39 patients with previous negative TRUS biopsy, but high clinical suspicion of occult prostate cancer, prospectively underwent prostate MRI including diffusion-weighted imaging (DWI). Patients with a suspicious anterior lesion on MRI underwent targeted anterior gland TRUS-guided biopsy with cognitive fusion technique using sagittal probe orientation. PIRADS version 1 scores (T2, DWI, and overall), lesion size, prostate-specific antigen (PSA), PSA density, and prostate gland volume were compared between positive and negative biopsy groups and between clinically significant cancer and remaining cases. Logistic regression analysis of imaging parameters and prostate cancer diagnosis was performed. Anterior gland prostate adenocarcinoma was diagnosed in 18 patients (46.2%) on targeted anterior gland TRUS-guided biopsy. Clinically significant prostate cancer was diagnosed in 13 patients (33.3%). MRI lesion size, T2, DWI, and overall PIRADS scores were significantly higher in patients with positive targeted biopsies and those with clinically significant cancer (P < 0.05). Biopsies were positive in 90%, 33%, and 29% of patients with overall PIRADS scores of 5, 4, and 3 respectively. Overall PIRADS score was an independent predictor of all prostate cancer diagnosis and of clinically significant prostate cancer diagnosis. Targeted anterior gland TRUS-guided biopsy with MRI-directed cognitive fusion enables accurate sampling and may improve tumor detection yield of anterior prostate cancer.

Performance of the Prostate Health Index in predicting prostate biopsy outcomes among men with a negative digital rectal examination and transrectal ultrasonography.

The [-2]proPSA (p2PSA) and its derivatives, the p2PSA-to-free PSA ratio (%p2PSA), and the Prostate Health Index (PHI) have greatly improved discrimination between men with and without prostate cancer (PCa) in prostate biopsies. However, little is known about their performance in cases where a digital rectal examination (DRE) and transrectal ultrasonography (TRUS) are negative. A prospective cohort of 261 consecutive patients in China with negative DRE and TRUS were recruited and underwent prostate biopsies. A serum sample had collected before the biopsy was used to measure various PSA derivatives, including total prostate-specific antigen (tPSA), free PSA, and p2PSA. For each patient, the free-to-total PSA ratio (%fPSA), PSA density (PSAD), p2PSA-to-free PSA ratio (%p2PSA), and PHI were calculated. Discriminative performance was assessed using the area under the receiver operating characteristic curve (AUC) and the biopsy rate at 91% sensitivity. The AUC scores within the entire cohort with respect to age, tPSA, %fPSA, PSAD, p2PSA, %p2PSA, and PHI were 0.598, 0.751, 0.646, 0.789, 0.814, 0.808, and 0.853, respectively. PHI was the best predictor of prostate biopsy results, especially in patients with a tPSA of 10.1–20 ng ml−1. Compared with other markers, at a sensitivity of 91%, PHI was the most useful for determining which men did not need to undergo biopsy, thereby avoiding unnecessary procedures. The use of PHI could improve the accuracy of PCa detection by predicting prostate biopsy outcomes among men with a negative DRE and TRUS in China.

Fusion Target Biopsy of the Prostate Using Real-Time Ultrasound and MR Images. A Multicenter RCT on Target Biopsy Techniques in the Diagnosis of Prostate Cancer

Background: The current standard technique for prostate cancer detection is trans-rectal ultrasound (TRUS) guided biopsy, and is renowned for its low sensitivity. Developments of multiparametric MRI techniques have increased the detection of significant prostate cancer. Currently there are three techniques utilizing MRI for targeted biopsy; MRI-TRUS fusion; ‘cognitive’ TRUS, and in-bore MRI guided biopsy. There is no consensus which should be preferred. The current study aims to compare prostate cancer detection rates of three target biopsy procedures. Methods: The FUTURE trial is a three-arm randomised controlled, multicentre trial comparing three techniques of MRI targeted biopsy of the prostate amongst subjects with one prior negative TRUS biopsy and a persisting suspicion on prostate cancer. All subjects undergo mpMRI imaging. Images will be centrally reviewed, and evaluated using the ‘Prostate imaging reporting and data system’. An estimated 69% of the subjects will demonstrate tumour suspicious findings on mpMRI, and will be randomised 1:1:1. The primary objective is to compare (significant) tumor detection rates of the three techniques. Secondary objectives include histopathological validation of mpMRI imaging and PI-RADS classification, a cost-effectiveness analysis, and follow-up after a negative mpMRI or negative target biopsy. All biopsy cores will be evaluated by one dedicated uro-pathologists per center. Two sub-investigations were based on the hypothesis that MRI-TRUS fusion and in-bore MRI biopsy demonstrate similar tumor detection, whilst MRI-TRUS fusion demonstrates increased tumor detection compared to ‘cognitive’ TRUS biopsy. A total number 466 of subjects is needed for equal randomization. Assuming that 69% of subjects have tumor suspicious findings on MRI imaging, a total of 675 subjects are required for inclusion. Discussion: For target biopsy procedures of the prostate the ultimate comparator is histopathological examination of radical prostatectomy specimens, though this leads to insurmountable ethical objections and thus to a methodological dilemma concerning validation.

The role of transurethral resection of the prostate for patients with an elevated prostate-specific antigen.

PurposeThe aim of this study was to define the clinical significance of transurethral resection of the prostate (TURP) in patients with benign prostate hyperplasia (BPH) and an elevated prostate-specific antigen (PSA) level.MethodsWe retrospectively evaluated patients with BPH, lower urinary tract symptoms (LUTS; International Prostate Symptom Score [IPSS]≥8), an elevated serum PSA level (≥4 ng/mL), and previous negative transrectal ultrasonography (TRUS) guided prostate biopsy. The PSA level after TURP was monitored by long-term follow-up. The tumor detection rate on resected prostate tissue, IPSS, maximal urinary flow rate (Qmax), and postvoid residual urine (PVR) were analyzed.ResultsOne-hundred and eighty-six patients were enrolled. Histological examination of resected tissue by TURP revealed prostate cancer in 12 of these patients (6.5%). Among 174 patients without prostate cancer, the mean PSA level and the PSA normalization rate in 112 patients followed up at postoperative day (POD) 3 months were 1.26±0.13 ng/mL and 94.6%, respectively. The mean PSA level and the PSA normalization rate were 1.28±1.01 ng/mL and 95.7% in 47 patients at 1st year, 1.17±0.82 ng/mL and 97.1% in 34 patients at second years, and 1.34±1.44 ng/mL and 97.2% in 36 patients at third years of TURP. One patient showed a dramatic increase in the PSA level was diagnosed with prostate cancer at 7 years after TURP. IPSS, quality of life, Qmax, and PVR were improved significantly at POD 3 months compared to baseline (P<0.05), respectively.ConclusionsTURP significantly reduced the serum PSA level, which was maintained for at least 3 years. This could be helpful to screen the prostate cancer using PSA value in the patient with previous negative biopsy and elevated PSA. In addition, TURP improves IPSS, Qmax, and PVR in patients with BPH, moderate LUTS, and an elevated PSA level.

3-Tesla magnetic resonance imaging improves the prostate cancer detection rate in transrectral ultrasound-guided biopsy.

The detection rate of prostate cancer (PCa) using traditional biopsy guided by transrectal ultrasound (TRUS) is not satisfactory. The aim of this study was to determine the utility of 3-Tesla (3-T) magnetic resonance imaging (MRI) prior to TRUS-guided prostate biopsy and to investigate which subgroup of patients had the most evident improvement in PCa detection rate. A total of 420 patients underwent 3-T MRI examination prior to the first prostate biopsy and the positions of suspicious areas were recorded respectively. TRUS-guided biopsy regimes included systematic 12-core biopsy and targeted biopsy identified by MRI. Patients were divided into subgroups according to their serum prostate-specific antigen (PSA) levels, PSA density (PSAD), prostate volume, TRUS findings and digital rectal examination (DRE) findings. The ability of MRI to improve the cancer detection rate was evaluated. The biopsy positive rate of PCa was 41.2% (173/420), and 41 of the 173 (23.7%) patients were detected only by targeted biopsy in the MRI-suspicious area. Compared with the systematic biopsy, the positive rate was significantly improved by the additional targeted biopsy (P=0.0033). The highest improvement of detection rate was observed in patients with a PSA level of 4–10 ng/ml, PSAD of 0.12–0.20 ng/ml2, prostate volume >50 ml, negative TRUS findings and negative DRE findings (P<0.05). Therefore, it is considered that 3-T MRI examination could improve the PCa detection rate on first biopsy, particularly in patients with a PSA level of 4–10 ng/ml, PSAD of 0.12–0.20 ng/ml2, prostate volume of >50 ml, negative TRUS findings and negative DRE findings.

MP53-17 TRANSPERINEAL TEMPLATE PROSTATE BIOPSIES: THE NEW GOLD STANDARD FOR PROSTATE CANCER DIAGNOSIS

You have accessJournal of UrologyProstate Cancer: Detection & Screening II1 Apr 2014MP53-17 TRANSPERINEAL TEMPLATE PROSTATE BIOPSIES: THE NEW GOLD STANDARD FOR PROSTATE CANCER DIAGNOSIS Shady Nafie, John Dormer, John Kilian Mellon, and Masood Ahmed Khan Shady NafieShady Nafie More articles by this author , John DormerJohn Dormer More articles by this author , John Kilian MellonJohn Kilian Mellon More articles by this author , and Masood Ahmed KhanMasood Ahmed Khan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1648AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Transrectal Ultrasound (TRUS) guided prostate biopsy is regarded as the gold standard for prostate cancer diagnosis. Transperineal template prostate biopsy (TPTPB) has been shown to improve prostate cancer detection in men with a rising PSA and previous negative TRUS guided prostate biopsies. We performed a prospective study directly comparing the prostate cancer detection rate between TRUS guided biopsy and TPTPB in 50 men with a benign feeling DRE, PSA < 20 ng/mL and no previous prostate biopsies. Methods 50 patients with a mean age of 67 years (range: 54-84), mean prostate volume of 58 cc (range:19-165) and mean PSA of 8 ng/L (range: 4-18) underwent standard 12-core TRUS guided prostate biopsy followed immediately by 36-core TPTPB under general anesthetic. We determined the prostate cancer detection rate between the two diagnostic modalities. Results A total of 20/50 (40%) men had benign pathology. Of the 30/50 (60%) diagnosed with prostate cancer 16 (32%) had positive results in both TRUS and TPTPB, while 14 (28%) had negative TRUS but positive TPTPB. Hence, TRUS guided prostate biopsy detected cancer in 32% whereas it was 60% with TPTPB. Furthermore, no cancers were detected solely by TRUS biopsy. In 19/30 (63%) the cancers detected by TPTPB had Gleason score ≥ 7. In total, 2 (4%) patients experienced urosepsis, 7 (14%) temporary urinary retention, 16 (32%) had mild haematuria and 19 (38%) haematospermia. Conclusions TPTPB is associated with a significantly higher prostate cancer detection rate compared to TRUS biopsies (60% vs. 32%, p<0.0001) in men with an elevated PSA < 20 ng/mL and a benign feeling prostate. We propose that TPTPB should be regarded as the biopsy technique of choice in this group of men. In addition, PSA appears to be a better biomarker for prostate cancer than previously thought. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e595 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Shady Nafie More articles by this author John Dormer More articles by this author John Kilian Mellon More articles by this author Masood Ahmed Khan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The role of transperineal template prostate biopsies in prostate cancer diagnosis in biopsy naïve men with PSA less than 20 ng ml−1

To compare prostate cancer detection rates between transrectal ultrasound (TRUS) prostate biopsy and transperineal template prostate biopsy (TPTPB) in biopsy naïve men. TRUS biopsy is still regarded as gold standard for prostate cancer diagnosis. TPTPB has been shown to improve prostate cancer detection in men with rising PSA and previous negative TRUS biopsies. We carried out a prospective study performing both biopsies in the same group of men with a benign feeling digital rectal examination (DRE), PSA <20 ng ml(-1) and no previous prostate biopsies. A total of 50 patients with mean age of 67 years (range: 54-84), mean prostate volume 58 cc (range: 19-165) and mean PSA 8 ng l(-1) (range: 4-18) underwent standard 12-core TRUS biopsy followed immediately by 36-core TPTPB under general anaesthetic. We determined the prostate cancer detection rate between the two diagnostic modalities. In total, 20/50 (40%) had benign pathology. Of 30/50 (60%) diagnosed with prostate cancer, 16 (32%) had positive results in both TRUS and TPTPB, whereas 14 (28%) had negative TRUS but positive TPTPB. No cancers were detected solely by TRUS biopsy. TRUS biopsy detected cancer in 32% versus 60% with TPTPB. In total, 19/30(63%) cancers detected by TPTPB had Gleason score > or =7.2 (4%) experienced urosepsis, 7 (14%) temporary urinary retention, 16 (32%) mild haematuria and 19 (38%) haematospermia. TPTPB is associated with significantly higher prostate cancer detection rate than TRUS biopsies in biopsy naïve men with a benign feeling DRE and PSA <20 ng ml(-1). PSA appears to be better biomarker than previously thought.

Transperineal template prostate biopsies in men with raised PSA despite two previous sets of negative TRUS-guided prostate biopsies

The possibility of prostate cancer as a cause for steadily rising PSA despite previously negative transrectal ultrasound (TRUS)-guided prostate biopsies is a major concern. An initial negative TRUS-guided prostate biopsy does not necessarily exclude the presence of clinically significant prostate cancer. We determined the role of transperineal template prostate biopsy (TPTPB) in prostate cancer detection in men with raised PSA despite two previous sets of negative TRUS biopsies. Between January 2008 and August 2012, a total of 122 men's records were reviewed after having 36-core TPTPB following two previous sets of negative TRUS biopsies despite raised PSA. A retrospective record of PSA levels, clinicopathological parameters and histological outcomes was made. Mean age was 63 years (range 49-77), and mean PSA was 18.0 (range 2.0-119.0). A total of 71/122 (58 %) men were diagnosed with prostate cancer on TPTPB. Of these, 28 (39 %), 34 (48 %), 5 (7 %), and 4 (6 %) had Gleason score 6, 7 (3 + 4), 7 (4 + 3), and 9 (4 + 5), respectively. The mean number of positive cores was 7 (range 1-22). Of these, only 15 (21 %) had ≤2 cores positive and Gleason score of 6. Of the 51 (42 %) men with a negative histology on TPTPB, 11 (22 %), 10 (19 %), and 30 (59 %) had atypical small acinar proliferation, high-grade prostatic intraepithelial neoplasia, or benign pathology. TPTPB is associated with a high rate of clinically significant prostate cancer diagnosis (58 %) in men with raised PSA despite two previous sets of negative TRUS biopsies.

Population‐based analysis of prostate‐specific antigen (PSA) screening in younger men (&lt;55 years) in Australia

To analyse the trends in opportunistic PSA screening in Australia, focusing on younger men (<55 years of age), to examine the effects of this screening on transrectal ultrasonography (TRUS)-guided biopsy rates and to determine the nature of prostate cancers (PCas) being detected. All men who received an opportunistic screening PSA test and TRUS-guided biopsy between 2001 and 2008 in Australia were analysed using data from the Australian Cancer registry (Australian Institute of Health and Welfare) and Medicare databases. The Victorian cancer registry was used to obtain Gleason scores. Age-standardized and age-specific rates were calculated, along with the incidence of PCa, and correlated with Gleason scores. A total 5 174 031 PSA tests detected 128 167 PCas in the period 2001-2008. During this period, PSA testing increased by 146% (a mean of 4629 tests per 100 000 men annually), with 80 and 59% increases in the rates of TRUS-guided biopsy and incidence of PCa, respectively. The highest increases in PSA screening occurred in men <55 years old and up to 1101 men had to be screened to detect one incident case of PCa (0.01%). Screening resulted in two thirds of men aged <55 years receiving a negative TRUS biopsy. There was no correlation with Gleason >7 tumours in patients aged <55 years. Despite the ongoing controversy about the merits of PCa screening, there was an increase in PSA testing, especially in men <55 years old, leading to a modestly higher incidence of PCa in Australia. Overall, PSA screening was associated with high rates of negative TRUS-biopsy and the detection of low/intermediate grade PCa among younger patients.

The accuracy of multiparametric MRI in men with negative biopsy and elevated PSA level—Can it rule out clinically significant prostate cancer?

PurposeTo assess the performance of multiparametric magnetic resonance imaging (mp-MRI) in patients with previous negative transrectal ultrasound (TRUS) guided prostate biopsy. Materials and methodsFifty-four patients with at least 1 previous negative TRUS prostate biopsy underwent mp-MRI in the form of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced imaging. This was followed by transperineal template systematic prostate biopsies. Analysis was done based on 2 sectors per prostate, right and left (108 sectors out of 54 prostates). mp-MRI was scored using an ordinal scale 1 to 5 based on the suspicion of the presence of clinically significant disease. We used 6 different definitions for clinically significant disease and tested the performance of mp-MRI at each single definition. ResultsMedian age was 64 (range, 39–75), median PSA level was 10 (range, 2–23), and median number of biopsies was 45 (range, 21–137). Cancer of any volume and any grade was detected in 34 of 54 (63%) patients. mp-MRI accuracy at detection of clinically significant cancer using University College London (UCL) definition 2 (any Gleason score of 4 or maximum cancer core length of ≥4mm or both) showed sensitivity of 76%, specificity of 42%, positive predictive value of 38%, and negative predictive value of 79%. For a different definition of significant tumor (UCL definition 1; dominant Gleason score 4 or maximum cancer core length ≥6mm or both), the sensitivity was 90%, specificity 42%, positive predictive value 26%, and negative predictive value 95%. Conclusionsmp-MRI showed good performance at both detection and ruling out clinically significant disease, according to the definition used. mp-MRI can then be used as a triage test in the population with persistently elevated or rising PSA levels to select patients that can avoid unnecessary prostate biopsy.