Positive Digital Rectal Examination Research Articles

Factors associated with pain sensation in patients with ultrasound-guided prostate biopsy.

TRUS-guided prostate biopsy is a current method used to obtain the histopathological material necessary to make a definitive diagnosis of prostate cancer. To investigate patient-related variables affecting the level of pain felt during prostate biopsy to determine what can be done to minimize pain. The study included 241 patients scheduled for prostate biopsy. Four patients who did not meet the criteria were excluded. Local anesthesia was administered intrarectally 10 minutes before the biopsy to 237 patients, and a conventional 12-core biopsy was performed. The level of pain felt by all patients during the biopsy was measured using the Visual Analog Scale (VAS) score. Pain scores were compared by forming groups according to the selected parameters. The mean age of the 237 included patients was 66.0±7.8 years, the mean serum PSA level was 33.7±197.5 ng/dL, and the mean prostate volume was 33.7±197.5 ml. The mean VAS score was 4.3±1.9. The pain score was higher in patients with positive digital rectal examination findings and lower in patients using 5-alpha reductase inhibitors(5-ARİ). At the same time, no significant difference was found in patients with positive tumor pathology, perineural invasion, alpha-blockers, or combination therapy. Some patient parameters may affect the level of pain felt during TRUS-guided prostate biopsy.

Prostate Biopsy May Not Be Indicated Early after Bacillus Calmette Guérin Treatment.

Bacillus Calmette-Guérin (BCG) treatment for non-muscle-invasive bladder cancer frequently causes an intraprostatic BCG granuloma. We investigated the optimal timing for a prostate biopsy after BCG treatment by retrospectively analyzing the cases of 22 patients with non-muscle-invasive bladder cancer who underwent a prostate biopsy after BCG treatment at our institute (2013-2017). Biopsies were indicated for a rising prostate-specific antigen (PSA) level, positive digital rectal examination findings, or the appearance of de novo low apparent diffusion coefficient lesions on MRI. The control group was comprised of 28 age- and PSA-matched patients. The relationships among the cancer detection rate and the patients' PSA levels and MRI findings were analyzed. Prostate cancer was detected by biopsy in only 13.9% (3/22) of the patients in the BCG group but in 78.5% (22/28) of the control patients (p=0.0001). The three patients in the BCG group in whom prostate cancer was detected had all undergone the biopsy > 1 year after their BCG treatment. The remaining biopsies were performed within 1 year after BCG treatment and resulted in no diagnoses of prostate cancer. We suggest that performing a prostate biopsy early after BCG treatment is not informative or useful.

Triad of serum PSA, DRE and biopsy in diagnosing prostatic diseases- How useful it is?

Prostate specific antigen (PSA) is a glycoprotein produced by prostatic acini and prostatic tissue. Its concentration increases in prostatic diseases. Concentration above 4 ng/ml is considered abnormal but there is no clear-cut point between normal and abnormal PSA levels. PSA is considered as serum marker for prostatic cancer but it is organ specific, not cancer specific. Digital rectal examination (DRE) is a routine part of prostate cancer screening. Biopsies are performed when PSA test and DRE are abnormal. The study is an attempt for comparative analysis among serum PSA, age, DRE, and biopsy results for the institution of specific treatment at an early stage. Study was performed on 200 patients with different prostatic lesions in the Department of Pathology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh. Clinical, DRE, PSA and histopathological biopsy were performed and analyzed by correlating the data. In our study 77.5% had normal (0-4 ng/ml) PSA level and 13.5% had >10 ng/ml PSA levels. BPH was the most common diagnosis (54.0%), followed by prostatitis (20.0%), BPH with prostatitis in 16.0% and carcinoma (10.0%). Serum PSA with positive DRE ranged from 1.2 ng/ml to 56 ng/ml while in negative DRE ranged from 0.18 ng/ml to 9.6 ng/ml. PSA is specific for prostate but not for prostatic diseases. With increasing age serum PSA also increases. Conjunction of serum PSA with other variables like age, DRE and biopsy makes a better diagnosis of prostatic diseases.

The feasibility of distance to the tumor of biopsy cores to estimate the extracapsular extension

BackgroundTo investigate the predictive capability of a new parameter, the distance between the fibromuscular capsule and the tumor as measured using a prostate biopsy core (referred to as “distance to the tumor” [DTT]), for the presence of extracapsular extension (ECE). Materials and methodsWe analyzed specimens obtained from 246 patients diagnosed with prostate cancer. All patients underwent prebiopsy, prostate magnetic resonance imaging (MRI), and subsequent prostatectomy. DTT measurements were obtained for each prostate biopsy core, and the minimum (min) DTT was extracted. We assessed the relationship between min DTT, MRI-estimated ECE, and pathological ECE, considering factors such as the PI-RADS score and tumor location. ResultsIn this study of 246 patients, the mean age was 65.8 years, and the mean prostate-specific antigen (PSA) level was 18.9 ng/ml. Patients with suspicious lesions in the peripheral zone and pathological ECE displayed higher rates of positive digital rectal examination (DRE), elevated PSA levels, and shorter DTT values in the biopsy cores. DTT demonstrated an accurate estimation of the presence of ECE, similar to MRI findings. Min DTT exhibited higher accuracy for peripheral zone masses, with a cutoff value of 1.0 mm for min DTT predicting ECE (AUC: 0.84, sensitivity: 72.23%, specificity: 77.78%, P < 0.01). Of the 246 patients, 66 had no ECE on MRI; however, 18 of these patients displayed pathological ECE, with 14 having DTT values <1.0 mm. ConclusionsMin DTT, positive DRE results, and a higher Gleason grade were significantly associated with ECE. DTT measurements of <1 mm can provide a more accurate prediction of ECE in the peripheral zone of the prostate than MRI-based assessments.

Metabolic Syndrome is Associated with Prostate Cancer Diagnosed on Biopsy but not the Gleason Score and the Number of Cancer-Positive Cores: A Prospective Controlled Study.

We aimed to investigate the association between metabolic syndrome (MetS) and prostate cancer (PCa) in patients undergoing prostate biopsy. Between January 2018 and December 2022, MetS was investigated according to Adult Treatment Panel III (ATP III) criteria in men who underwent prostate biopsy with transrectal ultrasound (TRUS). Clinicopathological factors such as, digital rectal examination (DRE), prostate-specific antigen (PSA), prostate volume, waist circumference, body mass index (BMI), age, blood pressure, testosterone, lipid profiles, fasting blood glucose level, C-reactive protein (CRP) and MetS were analyzed. A total of 908 men underwent biopsies, of which 492 (51.5%) had MetS according to ATP III criteria. The number of patients diagnosed with PCa in biopsy was 270 (29.7%). PCa cases were significantly older, with a lower prostate volume and a higher PSA value and higher blood pressure compared to patients without PCa (p < 0.001). 146 of 416 (35.0%) patients with MetS had PCa while 124 of 492 (25.2%) patients without MetS had PCa (p < 0.001). Out of 270 patients with PCa, 174 (64.4%) had Gleason score <7 and 96 (35.6%) had Gleason score ≥7. In patients with a Gleason score ≥7, PSA, DRE(+) and core positive number were significantly higher compared to patients with Gleason score <7, while glycemia and high-density lipoprotein (HDL) cholesterol levels were significantly lower (p < 0.001). Multivariate analysis showed that age, PSA, positive DRE, prostate volume (p < 0.001), diastolic blood pressure, CRP and MetS were the only independent parameters associated with a higher risk of cancer on biopsy (p < 0.05). Our findings show that MetS is associated with PCa diagnosed on biopsy but not with the Gleason score and the number of cancer-positive cores. However, these results should be confirmed by larger, multicenter and prospective studies.

A Prospective Comparison of Transrectal Standard, Cognitive, Transperineal Fusion, and Mapping Prostate Biopsy for Cancer Detection.

Purpose: The aim of this research was to compare the clinically significant prostate cancer (csPCa) detection rate (International Society of Urological Pathology [ISUP] ≥2) for the four biopsy methods: transrectal ultrasound-guided biopsy (TRUS-GB), cognitive transrectal biopsy (COG-TB), fusion transperineal biopsy (FUS-TB), and transperineal template mapping biopsy (TPMB). Materials and Methods: The inclusion criteria were as follows: prostate-specific antigen (PSA) >2 ng/mL, and/or positive digital rectal examination (DRE), and/or suspicious lesion on transrectal ultrasound (TRUS) and Prostate Imaging Reporting and Data System (Pi-RADS) v2.1 ≥ 3 score. In total, 102 patients were enrolled in the study. Biopsies were performed by two urologists. In a single procedure, the first urologist performed a FUS-TB and TPMB followed by second urologist who performed TRUS-GB and COG-TB. All specimens were obtained within a single procedure. Results: The csPCa detection rate and overall cancer detection rate (CDR) per patient were comparable among the respective biopsy methods (p > 0.05). Compared with other biopsy methods, a lower clinically insignificant prostate cancer (cisPCa) was detected using COG-TB (p = 0.004). The positive cores percentage ratio (p < 0.001) as well as positive cores containing csPCa percentage ratio (p < 0.001) significantly increased for the targeted biopsy methods. The median maximum cancer core length (MCCL; p = 0.52) as well the median for the MCCL of csPCa (p = 0.47) did not differ significantly among the respective biopsy methods. Concordance of the Gleason scores between biopsy and postprostatectomy pathology did not differ significantly among biopsy methods (p = 0.87). For TRUS-GB, FUS-TB, and TPMB, the common predictive factors for csPCa were positive DRE, suspicious lesion on ultrasound and Pi-RADS 5. As for COG-TB, the only predictor was Pi-RADS 5. Conclusion: The targeted methods did not show an increase in detection of csPCa and overall CDR over systematic ones in patients with Pi-RADS ≥3. A lower cisPCa was detected using COG-TB in comparison with the other methods. The sampling efficiency increased for the targeted biopsy methods, which used only a proportion of positive cores and cores containing csPCa. There was no statistical difference in histology concordance among the biopsies. One common predictive factor of increased csPCa detection for all biopsy methods was Pi-RADS 5.

Predictors of Prostate Cancer at Fusion Biopsy: The Role of Positive Family History, Hypertension, Diabetes, and Body Mass Index

PSA density and an elevated PI-RADS score are among the strongest predictors of prostate cancer (PCa) in a fusion biopsy. Positive family history, hypertension, diabetes, and obesity have also been associated with the risk of developing PCa. We aim to identify predictors of the prostate cancer detection rate (CDR) in a series of patients undergoing a fusion biopsy. We retrospectively evaluated 736 consecutive patients who underwent an elastic fusion biopsy from 2020 to 2022. Targeted biopsies (2-4 cores per MRI target) were followed by systematic mapping (10-12 cores). Clinically significant PCa (csPCa) was defined as ISUP score ≥ 2. Uni- and multi-variable logistic regression analyses were performed to identify predictors of CDR among age, body mass index (BMI), hypertension, diabetes, positive family history, PSA, a positive digital rectal examination (DRE), PSA density ≥ 0.15, previous negative biopsy status, PI-RADS score, and size of MRI lesion. The median patients' age was 71 years, and median PSA was 6.6 ng/mL. A total of 20% of patients had a positive digital rectal examination. Suspicious lesions in mpMRI were scored as 3, 4, and 5 in 14.9%, 55.0%, and 17.5% of cases, respectively. The CDR was 63.2% for all cancers and 58.7% for csPCa. Only age (OR 1.04, p < 0.001), a positive DRE (OR 1.75, p = 0.04), PSA density (OR 2.68, p < 0.001), and elevated PI-RADS score (OR 4.02, p = 0.003) were significant predictors of the CDR in the multivariable analysis for overall PCa. The same associations were found for csPCa. The size of an MRI lesion was associated with the CDR only in uni-variable analysis (OR 1.07, p < 0.001). BMI, hypertension, diabetes, and a positive family history were not predictors of PCa. In a series of patients selected for a fusion biopsy, positive family history, hypertension, diabetes, or BMI are not predictors of PCa detection. PSA-density and PI-RADS score are confirmed to be strong predictors of the CDR.

Stability of Prognostic Estimation Using the CAPRA Score Incorporating Imaging-based vs Physical Exam-based Staging.

Although official T-staging criteria for prostate cancer are based on digital rectal examination findings, providers increasingly rely on transrectal US and MRI to define pragmatic clinical stage to guide management. We assessed the impact of incorporating imaging findings into T-staging on performance of a well-validated prognostic instrument. Patients who underwent radical prostatectomy for prostate cancer diagnosed between 2000 and 2019 with stage ≤cT3a on both digital rectal examination and imaging (transrectal US/MRI) were included. The University of California, San Francisco CAPRA (Cancer of the Prostate Risk Assessment) score was computed 2 ways: (1) incorporating digital rectal examination-based T stage and (2) incorporating imaging-based T stage. We assessed for risk changes across the 2 methods and associations of CAPRA (by both methods) with biochemical recurrence, using unadjusted and adjusted Cox proportional hazards models. Model discrimination and net benefit were assessed with time-dependent area under the curve and decision curve analysis, respectively. Of 2,222 men included, 377 (17%) increased in CAPRA score with imaging-based staging (P < .01). Digital rectal examination-based (HR 1.54; 95% CI 1.48-1.61) and imaging-based (HR 1.52; 95% CI 1.46-1.58) CAPRA scores were comparably accurate for predicting recurrence with similar discrimination and decision curve analyses. On multivariable Cox regression, positive digital rectal examination at diagnosis (HR 1.29; 95% CI 1.09-1.53) and imaging-based clinical T3/4 disease (HR 1.72; 95% CI 1.43-2.07) were independently associated with biochemical recurrence. The CAPRA score remains accurate whether determined using imaging-based staging or digital rectal examination-based staging, with relatively minor discrepancies and similar associations with biochemical recurrence. Staging information from either modality can be used in the CAPRA score calculation and still reliably predict risk of biochemical recurrence.

Correlation of multiparametric MRI with histopathological grade of peripheral zone prostate carcinoma.

Prostatic cancer is the second most common malignant tumor in men. Preoperative grading of prostate cancer is important for its management. Our objective is to compare individual and combined detection rates of T2-weighted imaging (T2WI), diffusion weighted imaging (DWI), dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI), and magnetic resonance spectroscopy (MRS) for prostate cancer with histopathological diagnosis as its golden standard. Forty-four patients with positive digital rectal examination (DRE) findings and elevated prostate specific antigen (PSA), underwent multiparametric MRI (Mp-MRI). T2WI, DWI, DCE-MRI and MRS were done in all the patients. Cognitive magnetic resonance-transrectal ultrasound (MR-TRUS) fusion biopsy was done in all the patients. Sensitivity and specificity of T2WI, DWI, DCE-MRI, and Prostate Imaging - Reporting and Data System PIRADS version 2 was obtained. Apparent diffusion coefficient (ADC) value and choline/citrate ratio were obtained for each lesion and correlated with histopathological grade. The mean age of the patients was 68.7 ± 10.1 years, and the mean serum PSA level was 58.1 ± 22.4 ng/dL. Of the 38 lesions in peripheral zone, 33 (87%) had histopathologically proven prostate cancer. T2WI had a sensitivity and specificity of 75.8% and 80% and DWI had a sensitivity and specificity of 90.9% and 80%, respectively, for detection of malignant prostatic lesion. The mean ADC values for prostate cancer, prostatitis, and normal prostatic parenchyma were 0.702 ± 0.094 × 10-3 mm2/sec, 0.959 ± 0.171 × 10-3 mm2/sec, and 1.31 ± 0.223 × 10-3 mm2/sec, respectively. Type 3 curve has lower sensitivity (45.5%) but high specificity (80%) for diagnosing prostate cancer. DWI can be useful to differentiate benign from malignant prostatic lesions, and low-grade from high-grade prostate carcinoma. ADC value has a positive correlation with histopathological grade of prostate cancer.

Predictors of Clinically Significant Prostate Cancer in Patients with PIRADS Categories 3-5 Undergoing Magnetic Resonance Imaging-Ultrasound Fusion Biopsy of the Prostate.

Prostate biopsy is recommended in cases of positive magnetic resonance imaging (MRI), defined as Prostate Imaging Reporting and Data System (PIRADS) category ≥ 3. However, most men with positive MRIs will not be diagnosed with clinically significant prostate cancer (csPC). Our goal was to evaluate pre-biopsy characteristics that influence the probability of a csPC diagnosis in these patients. We retrospectively analyzed 740 consecutive men with a positive MRI and no prior PC diagnosis who underwent MRI-ultrasound fusion biopsies of the prostate in three centers. csPC detection rates (CDRs) for each PIRADS category were calculated. Patient, disease, and lesion characteristics were studied for interdependencies with the csPC diagnosis. The CDR in patients with PIRADS categories 3, 4, and 5 was 10.5%, 30.7%, and 54.6%, respectively. On both uni- and multivariable regression models, older age, being biopsy-naïve, prostate specific antigen ≥ 10 ng/mL, smaller prostate volume, PIRADS > 3, a larger maximum lesion size, a lesion in the peripheral zone, and a positive digital rectal examination were associated with csPC. In this large, multicenter study, we provide new data regarding CDRs in particular PIRADS categories. In addition, we present several strong predictors that further alter the risk of csPC in MRI-positive patients. Our results could help in refining individual risk assessment, especially in PIRADS 3 patients, in whom the risk of csPC is substantially low.

Prostate cancer screening - is it time to change approach?

Prostate adenocarcinoma (CaP) is one of the most common malignancies in men in Slovakia and in the world. The disease accounts for more than 22% of all tumors in the male population. Screening studies show an increase in the diagnosis of CaP without improvement in overall or CaP-specific mortality. The main goal of the work is to evaluate the incidence of CaP in the group of patients examined and treated during the period from 2014 to 2019 at the urological outpatient clinic of the Railway Hospital (RH) in Košice, and to evaluate the risks and treatment options. Men aged 40 to 75 years underwent a preventive examination in 2014-2019 at the urology outpatient clinic, RH Košice. The number of screened patients was 3,943. Epidemiological parameter, diagnosis-related examinations (prostate specific antigen - PSA examination, digital rectal examination, and ultrasonography examination) as well as the frequency of examinations were monitored during the specified period on the basis of documentation. The number of prostate biopsies, incidence of prostate cancer and relation to PSA values were also monitored, as well as the classification of prostate cancers according to the degree of risk. Initial treatment in individual patients was also evaluated. PSA values in patients who underwent biopsy ranged from 3.6 ng/mL to 2,000 ng/mL. We observed positive digital rectal examination in 52 patients. Of the number of patients examined, 231 (61.28%) were positive biopsies. There were negative biopsies with the finding of benign prostatic hyperplasia in 92 patients or chronic prostatitis in 54 patients, i.e., 146 (38.72%). According to the criteria for risk assessment based on the PSA value and the result of the histological examination, we diagnosed 109 low-risk patients, 57 medium-risk patients and 24 high-risk patients. CaP is detected by prevention about 10 years before it develops clinically. The main aim of preventive examinations should be to detect, in particular, high-risk forms of early-stage prostate cancer and to improve the quality of life of men. Due to the results of extensive studies, it is necessary to continue the active search for prostate cancer. This reduces the risk of metastatic forms of CaP.

Association between obesity and frequency of high-grade prostate cancer on biopsy in men: A single-center retrospective study.

The present study aimed to investigate the relationship between BMI and the prostate cancer (PCa) risk at biopsy in Italian men. Retrospective analyses of the clinical data of 2,372 consecutive men undergoing ultrasound-guided multicore (≥10) prostate biopsy transrectally between May 2010 and December 2018 were performed. BMIs were categorized, according to Western countries' classification of obesity, as follows: <18.5 kg/m2 (underweight), 18.5-24.99 kg/m2 (normal weight), 25-30 kg/m2 (overweight) and >30 kg/m2 (obese). The distribution of patients undergoing biopsy was compared with a model population from the official survey data. Patient characteristics and the relationships between characteristics were investigated using correlation analysis, ANOVA, Kruskal-Wallis and Dunn's tests. The present study estimated the influence on cancer incidence not only of BMI but also of other patient characteristics using multi-variable logistic modelling and compared, using the models, the expected outcomes for patients who differed only in BMI. From a sample of 2,372 men, the present study enrolled 1,079 men due to a lack of clinical data [such as prostate specific antigen (PSA) and BMI data] in the other patients undergoing prostate biopsy. Their distribution was significantly different from the model distribution with the probability of undergoing biopsy increasing with increasing BMI. The median age was 69.4 years. The median BMI was 26.4 kg/m2, while the median PSA level was 7.60 ng/ml. In total, the biopsies detected PCa in 320 men (29.7%) and high-grade PCa (HGPCa) in 218 men (20.2%). Upon applying the aforementioned Western countries' criteria for BMI categories, there were 4 (0.4%) underweight, 318 (29.5%) of normal weight, 546 (50.6%) overweight, and 211 (19.6%) obese patients. ANOVA/Kruskal-Wallis tests revealed that overweight and obese men were younger than the normal-weight men, while there was no statistical difference in their PSA values. Furthermore, 29.3% of normal-weight men, 29.5% of overweight men and 29.9% of obese men were diagnosed with PCa, while 19.5% of normal-weight men, 20.1% of overweight men and 21.8% of obese men were affected by severe cancer. BMI was found to be positively correlated with PCa risk and negatively correlated with both age and PSA level. Age and PSA level were both positively correlated with PCa risk, while digital rectal examination (DRE) outcome was strongly indicative of PCa discovery if the test outcome was positive. Logistics models attributed a positive coefficient to BMI when evaluated against both PCa risk and HGPCa risk. In patients having a negative DRE outcome who differed only in BMI, logistic regression showed a 60% increased risk of PCa diagnosis in obese patients compared with in normal-weight patients. This risk difference increased when other characteristics were less indicative of PCa (younger age/lower PSA), while it decreased when patient characteristics were more indicative (older age/higher PSA, positive DRE). In conclusion, the present study demonstrated that, in men with higher BMIs, the risk of PCa is higher. The relative difference in risk between low and high BMI is most pronounced in younger patients having a lower PSA level and a negative DRE outcome.

The Application of Biopsy Density in Transperineal Templated-Guided Biopsy Patients With PI-RADS

BackgroundIn patients with multiparameter magnetic resonance imaging (mpMRI) low-possibility but highly clinical suspicion of prostate cancer, the biopsy core is unclear. Our study aims to introduce the biopsy density (BD; the ratio of biopsy cores to prostate volume) and investigates the BD-predictive value of prostate cancer and clinically significant prostate cancer (csPCa) in PI-RADS<3 patients.MethodsPatients underwent transperineal template–guided prostate biopsy from 2012 to 2022. The inclusion criteria were PI-RADS<3 with a positive digital rectal examination or persistent PSA abnormalities. BD was defined as the ratio of the biopsy core to the prostate volume. Clinical data were collected, and we grouped the patients according to pathology results. Kruskal–Wallis test and chi-square test were used in measurement and enumeration data, respectively. Logistics regression was used to choose the factor associated with positive biospy and csPCa. The receiver operating characteristic (ROC) curve was used to evaluate the ability to predict csPCa.ResultsA total of 115 patients were included in our study. Biopsy was positive in 14 of 115 and the International Society of Urological Pathology grade groups 2–5 were in 7 of all the PCa patients. The BD was 0.38 (0.24-0.63) needles per milliliter. Binary logistics analysis suggested that PSAD and BD were correlated with positive biopsy. Meanwhile, BD and PSAD were associated with csPCa. The ROC curve illustrated that BD was a good parameter to predict csPCa (AUC=0.80, 95% CI: 0.69-0.91, p<0.05). The biopsy density combined with PSAD increased the prediction of csPCa (AUC=0.90, 95% CI: 0.85-0.97, p<0.05). The cut-off value of the BD was 0.42 according to the Youden index.ConclusionIn PI-RADS<3 patients, BD and PSAD are related to csPCa. A biopsy density of more than 0.42 needles per millimeter can increase the csPCa detection rate, which should be considered as an alternative biopsy method when we perform prostate biopsy in patients with PI-RADS<3.

MP15-06 RISK OF ADVERSE RADICAL PROSTATECTOMY OUTCOMES IN PATIENTS DIAGNOSED WITH IUSP ≤2 PROSTATE CANCER ON MRI/TRUS FUSION BIOPSY

You have accessJournal of UrologyCME1 May 2022MP15-06 RISK OF ADVERSE RADICAL PROSTATECTOMY OUTCOMES IN PATIENTS DIAGNOSED WITH IUSP ≤2 PROSTATE CANCER ON MRI/TRUS FUSION BIOPSY Claudia Kesch, Vlad Pantea, Timo Soeterik, Alessandro Marquis, Giulia La Bombarda, Allesandro Morlacco, Francesco Barletta, Felix Preisser, Fabio Zattoni, Giancarlo Marra, Roderik C.N. van den Bergh, Jan Philipp Radtke, Boris Hadaschik, and Giorgio Gandaglia Claudia KeschClaudia Kesch More articles by this author , Vlad PanteaVlad Pantea More articles by this author , Timo SoeterikTimo Soeterik More articles by this author , Alessandro MarquisAlessandro Marquis More articles by this author , Giulia La BombardaGiulia La Bombarda More articles by this author , Allesandro MorlaccoAllesandro Morlacco More articles by this author , Francesco BarlettaFrancesco Barletta More articles by this author , Felix PreisserFelix Preisser More articles by this author , Fabio ZattoniFabio Zattoni More articles by this author , Giancarlo MarraGiancarlo Marra More articles by this author , Roderik C.N. van den BerghRoderik C.N. van den Bergh More articles by this author , Jan Philipp RadtkeJan Philipp Radtke More articles by this author , Boris HadaschikBoris Hadaschik More articles by this author , and Giorgio GandagliaGiorgio Gandaglia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002544.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To avoid overtreatment, active surveillance (AS) is recommended for prostate cancer (PC) patients with low- to favorable intermediate-risk features. However, previous studies based on 12-core transrectal ultrasound (TRUS) biopsy have demonstrated high upgrading rates (up to 70%) at radical prostatectomy (RP) in men potentially suitable for AS. We aim at exploring rate and risk factors for adverse pathologic outcomes in patients with multiparmetric magnetic resonance imaging (mpMRI)/TRUS fusion biopsy confirmed ISUP ≤2 PC. METHODS: Multicentre, retrospective analysis of 477 consecutive patients with ISUP ≤2 PC on mpMRI/TRUS fusion biopsy treated with RP. Adverse outcomes (AO) were defined as any ISUP upgrading, upgrading to ISUP ≥3, ≥pT3 at RP, any AO (=ISUP upgrading to ≥ 3 and/or ≥pT3 and/or N1) or biochemical recurrence (BCR) in men with available follow-up (n=327). Rates of AO were calculated for the overall cohort, biopsy ISUP 1 (n=149) and biopsy ISUP 2 (n=328) PC. Groups were compared using Qui-square test. Logistic regression was used to determine predictive factors. RESULTS: The overall rates of ISUP upgrading, ISUP upgrading to ≥ 3, ≥pT3 on RP and any AO were 39%, 21%, 32% and 43%, respectively. Compared to biopsy ISUP 2, men with biopsy ISUP 1 PC experienced more frequently ISUP upgrading (27% vs. 67%, p<0.001), but less ISUP upgrading to ≥ 3 (27% vs. 10%, p<0.001) and any AO (48% vs. 32%, p=0.001). No differences were recorded for ≥pT3 on RP (34% vs. 26%, p=0.052). PSA density, PIRADS score on mpMRI, number of positive targeted biopsy (TB) cores, ISUP of TB cores, overall number of biopsy cores and positive biopsy cores were all predictive factors for ISUP upgrading to ≥3, ≥pT3 at RP as well as for any AO. Neither PSA nor positive digital rectal examination significantly predicted AOs. Median time of follow-up was 12 months. The 1-year BCR-free survival was 94%. No significant differences in BCR rates were observed comparing men with biopsy ISUP 1 and biopsy ISUP 2 (5% vs. 7%, p=0.518). Positive TB cores, ISUP at RP, ISUP upgrading, ISUP upgrading to ≥3, ≥pT3 on RP and any AO were all predictive for BCR. CONCLUSIONS: In men with mpMRI/TRUS fusion biopsy confirmed ISUP ≤ 2 PC adverse outcomes at RP are still frequent. When counseling patients regarding AS, especially PSA density, ISUP, mpMRI findings and number of positive biopsy cores should be taken into account to identify the men at higher risk of AO. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e243 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Claudia Kesch More articles by this author Vlad Pantea More articles by this author Timo Soeterik More articles by this author Alessandro Marquis More articles by this author Giulia La Bombarda More articles by this author Allesandro Morlacco More articles by this author Francesco Barletta More articles by this author Felix Preisser More articles by this author Fabio Zattoni More articles by this author Giancarlo Marra More articles by this author Roderik C.N. van den Bergh More articles by this author Jan Philipp Radtke More articles by this author Boris Hadaschik More articles by this author Giorgio Gandaglia More articles by this author Expand All Advertisement PDF DownloadLoading ...

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

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

Nomogram predicting prostate cancer in patients with negative prebiopsy multiparametric magnetic resonance.

Aim: To build two nomograms for predicting the possibilities of prostate cancer (PCa) and clinically significant PCa (csPCa) in patients with negative prebiopsy multiparametric MRI (mpMRI). Methods: The independent predictors associated with PCa or csPCa in patients with negative mpMRI were determined and served in the construction of the two nomograms. Results: The nomogram predicting PCa consisted of age, positive digital rectal examination, free/total prostate-specific antigen (PSA) ratio and PSA density, while age, positive digital rectal examination and PSA density comprised the nomogram predicting csPCa. The negative predictive value of mpMRI for PCa and csPCa improved from 77.1 and 87.5% to 90.4 and 96.1%, respectively, in the training cohort (n=376) and from 81.9 and 89.0% to 91.8 and 96.5%, respectively, in the validation cohort (n=127) when combined with the two nomograms. Conclusion: The negative predictive value of negative mpMRI for the detection of PCa or csPCa was improved with the results of the nomograms.

Prostate cancer detection rate in men undergoing transperineal template-guided saturation and targeted prostate biopsy.

ObjectivesTo compare prostate cancer (PCa) detection rate of transperineal template‐guided saturation prostate biopsy (SBx) and multiparametric magnetic resonance imaging (mpMRI)/transrectal ultrasound fusion guided targeted biopsy (TBx).Materials and MethodsWe prospectively enrolled 392 men who underwent SBx and TBx in case of suspicious lesions from November 2016 to October 2019. Triggers for a biopsy were an elevated prostate‐specific antigen (PSA) and/or positive digital rectal examination and only treatment naïve patients without a previous diagnosis of PCa were included. Study inclusion occurred before biopsy and a prebiopsy mpMRI was available in all men. SBx were taken from 20 different locations according to the modified Barzell zones. The primary endpoint was the detection rate of clinically significant PCa (csPCa) and insignificant PCa (ciPCa) by SBx and/or TBx by comparing the two methods alone and in combination. Additional TBx were taken for any prostate imaging–reporting and data system (PI‐RADS) lesion ≥3 seen on the mpMRI. csPCa was defined as any Gleason score ≥7 and ciPCa as Gleason score 6.ResultsA total of 392 men with a median age of 64 years (interquartile range [IQR]: 58–69), a median PSA of 7.0 ng/ml (IQR: 4.8–10.1) were enrolled. Overall, PCa was found in 200 (51%) of all biopsied men, with 158 (79%) being csPCa and 42 (21%) ciPCa. A total of 268 (68%) men with a suspicious mpMRI and underwent a combined TBx and SBx, of whom csPCa was found in 139 (52%). In this subgroup, 116/139 (83%) csPCa would have been detected by TBx alone, and an additional 23 (17%) were found by SBx. Men with a negative mpMRI (PI‐RADS < 3, n = 124, 32%) were found to have csPCa in 19 (15%) cases. In patients with a negative mpMRI in combination with a PSA density <0.1 ng/ml2, only 8% (3/36) had csPCa. If only TBx would have been performed and all men with a negative mpMRI would not have been biopsed, 42/158 (27%) of csPCa would have been missed, and 38/42 (90%) ciPCa would have not been detected. On multivariable analysis, significant predictors of csPCa were increasing PSA (odds ratio, OR: 1.07 [95% confidence interval, CI: 1.03–1.11]), increasing age (OR: 1.07 [95% CI: 1.03–1.11]), PI‐RADS score ≥ 3 (OR: 6.49 [95% CI: 3.55–11.89]), and smaller prostate volume (OR: 0.96 [95% CI: 0.95 –0.97] (p < 0.05 for all parameters).ConclusionIn comparison to SBx, TBx alone detects csPCa in only ¾ of all men with a positive mpMRI lesion. Thus, systematic biopsies in addition to TBx have to be considered at least in some who undergo a prostate biopsy. In men with a negative mpMRI, SBx still detects 15% csPCa, but similarly overdetecting ciPCa. According to our results, low PSA density and negative mpMRI findings could be used to decide which men can safely avoid biopsy.

SUVmax/ADC Ratio as a Molecular Imaging Biomarker for Diagnosis of Biopsy-Naïve Primary Prostate Cancer.

Background:Gallium-68-prostate-specific membrane antigen (68Ga-PSMA) positron emission tomography/computed tomography (PET/CT) has recently been shown to be very high accuracy in biopsy-naïve prostate cancer (PCa) detection and can potentially improve the low specificity noted with diffusion-weighted magnetic resonance imaging (DW-MRI), especially in instances of prostate inflammation. We aimed to compare the diagnostic accuracy of DW-MRI and PSMA PET/CT using apparent diffusion coefficient (ADC) and maximum standardized uptake (SUVmax) values in the diagnosis of PCa.Patients and Methods:A retrospective study comparing and analyzing the diagnostic accuracy of prebiopsy DW-MRI and 68Ga-PSMA PET/CTs done in patients with suspected PCa (raised prostate specific antigen [PSA] and/or positive digital rectal examination) from January 2019 to December 2020. The standard of reference was transrectal ultrasound-guided biopsies.Results:Sixty-seven patients were included in the study, mean age: 70 years (range 49–84), mean PSA: 23.2 ng/ml (range 2.97–45.6). Biopsy was positive for PCa in 56% (n = 38) and negative in 43% (n = 29). Of the benign results, benign hyperplasia was noted in 75% (n = 22) and prostatitis in 25% (n = 7). Of the PCa, 55% (n = 21) of were high International Society of Urological Pathology (ISUP) grade (4–5) and 45% (n = 17) low/intermediate ISUP grade (1–3). Overall the sensitivity/specificity/Accuracy for prediction of PCa of MRI using prostate imaging and reporting data system version 2 criteria and PSMA PET/CT using PCa molecular imaging standardized evaluation criteria was 92.1%/65.5%/80.5% and 76.3%/96.5%/85.1% respectively. Mean apparent diffusion co-efficient (mean ADC) value of benign lesions and PCa was 1.135 × 10-3 mm2/s and 0.723 × 10-3 mm2/s, respectively (P = 0.00001). Mean SUVmax and ADC of benign and PCa lesions was 4.01 and 16.4 (P = 0.000246). Mean SUVmax/ADC ratio of benign and malignant lesions was 3.8 × 103 versus 25.21 × 103 (P < 0.000026). Inverse correlation was noted between ADC and SUVmax values (R = −0.609), inverse correlation noted between ADC and Gleason's score (R = −0.198), and positive correlation of SUVmax and SUVmax/ADC with Gleason's score (R = 0.438 and R = 0.448). Receiver operating characteristic curve analysis revealed a SUVmax cutoff 6.03 (sensitivity/specificity - 76%/90%, area under the curve (AUC) - 0.935, Youden index (YI) - 0.66), ADC cutoff of 0.817 × 10−3 mm2/s (sensitivity/specificity – 79%/86%, AUC – 0.890, YI - 0.65), and SUVmax/ADC ratio cutoff of 7.43 × 103 (sensitivity/specificity – 87%/98%, AUC - 0.966, YI - 0.85) for PCa diagnosis.Conclusion:For diagnosis of biopsy-naïve PCas, the combination of diffusion-weighted MRI and PSMA PET/CT (i.e., SUVmax/ADC ratio) shows better diagnostic accuracy than either used alone and the combination of PET and MRI is especially useful when distinguishing cancer from prostatitis.

MP15-17 PREDICTION MODEL FOR SIDE-SPECIFIC LYMPH NODE INVASION IN RADICAL PROSTATECTOMY AMONG PATIENTS WITH PROSTATE CANCER: FEASIBILITY OF SIDE-SPECIFIC LYMPH NODE DISSECTION

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP15)1 Sep 2021MP15-17 PREDICTION MODEL FOR SIDE-SPECIFIC LYMPH NODE INVASION IN RADICAL PROSTATECTOMY AMONG PATIENTS WITH PROSTATE CANCER: FEASIBILITY OF SIDE-SPECIFIC LYMPH NODE DISSECTION Eri Fukagawa, Noboru Numao, Shinya Yamamoto, Kasumi Yoshitomi, Kosuke Hamada, Yusuke Yoneoka, Motohiro Fujiwara, Ryo Fujiwara, Yoshinobu Komai, Tomohiko Oguchi, Takeshi Yuasa, Iwao Fukui, and Junji Yonese Eri FukagawaEri Fukagawa More articles by this author , Noboru NumaoNoboru Numao More articles by this author , Shinya YamamotoShinya Yamamoto More articles by this author , Kasumi YoshitomiKasumi Yoshitomi More articles by this author , Kosuke HamadaKosuke Hamada More articles by this author , Yusuke YoneokaYusuke Yoneoka More articles by this author , Motohiro FujiwaraMotohiro Fujiwara More articles by this author , Ryo FujiwaraRyo Fujiwara More articles by this author , Yoshinobu KomaiYoshinobu Komai More articles by this author , Tomohiko OguchiTomohiko Oguchi More articles by this author , Takeshi YuasaTakeshi Yuasa More articles by this author , Iwao FukuiIwao Fukui More articles by this author , and Junji YoneseJunji Yonese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001996.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although the pathway of lymph node invasion (LNI) in prostate cancer has anatomical variability and has not yet been clarified, it is known that lymphatic drainage to the contralateral side is less than that to the ipsilateral side. Considering this, it may be acceptable to evaluate the LNI side-specifically in radical prostatectomy (RP). In this study, we established a predictive model to estimate the probability of side-specific LNI in patients treated with RP, and evaluated the feasibility of omitting pelvic lymph node dissection (PLND) side-specifically. METHODS: The cohort consisted of 334 prostate cancer patients diagnosed with a combination of systematic and magnetic resonance imaging (MRI)-targeted biopsy who underwent RP and extended PLND without neoadjuvant treatment at our institution between 2012 and 2020. We determined the association between LNI and preoperative clinical factors both side- and patient-specifically. Clinical factors included prostate-specific antigen (PSA), clinical stage on MRI, digital rectal examination (DRE) findings, and biopsy results (Gleason grade group and percentage of positive cores). All LNI and clinical factors except for PSA were evaluated both side- and patient-specifically. RESULTS: Median age and PSA was 67 years and 8.1 ng/mL, respectively. LNI was found in 23/668 sides (3.4%) and 22/334 patients (6.6%). In the side-specific model, multivariate analysis showed significance between side-specific LNI and PSA≥10 ng/mL, positive ipsilateral DRE, ipsilateral biopsy Gleason grade group 5, and percentage of ipsilateral positive biopsy cores≥50%. When the sum of these risk factors is 0, 1, 2, 3, and 4, the actual probability of LNI was 0.4, 1.3, 6.0, 15, and 27% respectively. When this sum was ≤1 and ≤2, side-specific PLND could be omitted in 483 (72%) and 600 (90%) sides with missing four (0.8%) and eleven (1.8%) LNI, respectively. In the patient-specific model, multivariate analysis showed significance between LNI and PSA≥10 ng/mL, positive DRE, and biopsy Gleason grade group 5. When the sum of these risk factors is 0, 1, 2, and 3, the actual probability of LNI was 0.8, 4.6, 14, and 38%, respectively. When the sum was 0 and ≤1, bilateral PLND could be omitted in 121 (36%) and 252 (75%) patients with missing one (0.8%) and seven (2.8%) LNI, respectively. CONCLUSIONS: Our results suggest that, by predicting LNI side-specifically in RP, more PLND could be omitted side-specifically with a lower risk of missing LNI compared with patient-specific prediction. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e270-e270 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eri Fukagawa More articles by this author Noboru Numao More articles by this author Shinya Yamamoto More articles by this author Kasumi Yoshitomi More articles by this author Kosuke Hamada More articles by this author Yusuke Yoneoka More articles by this author Motohiro Fujiwara More articles by this author Ryo Fujiwara More articles by this author Yoshinobu Komai More articles by this author Tomohiko Oguchi More articles by this author Takeshi Yuasa More articles by this author Iwao Fukui More articles by this author Junji Yonese More articles by this author Expand All Advertisement Loading ...

MP11-01 HIGH-RESOLUTION MICRO-ULTRASOUND FOR LOCAL STAGING OF PROSTATE CANCER: A PROSPECTIVE SINGLE-CENTER EXPERIENCE

You have accessJournal of UrologyProstate Cancer: Staging (MP11)1 Sep 2021MP11-01 HIGH-RESOLUTION MICRO-ULTRASOUND FOR LOCAL STAGING OF PROSTATE CANCER: A PROSPECTIVE SINGLE-CENTER EXPERIENCE Vittorio Fasulo, Rozzano, Federica Regis, Marco Paciotti, Francesco Persico, Davide Maffei, Alessandro Uleri, Alberto Saita, Rodolfo Hurle, Massimo Lazzeri, Paolo Casale, Giorgio Guazzoni, Nicolò Buffi, and Giovanni Lughezzani Vittorio FasuloVittorio Fasulo More articles by this author , Rozzano Rozzano More articles by this author , Federica RegisFederica Regis More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Francesco PersicoFrancesco Persico More articles by this author , Davide MaffeiDavide Maffei More articles by this author , Alessandro UleriAlessandro Uleri More articles by this author , Alberto SaitaAlberto Saita More articles by this author , Rodolfo HurleRodolfo Hurle More articles by this author , Massimo LazzeriMassimo Lazzeri More articles by this author , Paolo CasalePaolo Casale More articles by this author , Giorgio GuazzoniGiorgio Guazzoni More articles by this author , Nicolò BuffiNicolò Buffi More articles by this author , and Giovanni LughezzaniGiovanni Lughezzani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001984.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recently, micro-ultrasound (microUS) has been proposed as an alternative to multiparametric magnetic resonance imaging for the diagnosis of clinically significant Prostate Cancer (PCa), but its role in the local staging of PCa has not been determined yet. Our aim was to evaluate the accuracy of microUS in predicting extraprostatic extension (EPE) of PCa prior to surgery. METHODS: This is a single-institutional prospective cohort study. Patients with biopsy-proven PCa scheduled for robot-assisted radical prostatectomy (RARP) were recruited. Patients with PSA>20ng/mL and a prostate volume>100 mL, were excluded. All patients underwent microUS before RARP. The following ultrasound features were evaluated as predictors of non-organ-confined disease: curvilinear contact length(CCL), capsular bulging, visible breach of the prostate capsule(visible extracapsular extension; ECE), presence of hypoechoic halo or ring, and obliteration of the vesicle-prostatic angle. The ability of each feature to predict EPE was determined. Multivariable logistic regression models (LRMs) were fitted to test the predictors of EPE, and their accuracy estimated with the area under the ROC-curve (AUC) analysis. The diagnostic performance of the most accurate predictor was tested. RESULTS: Overall, 140 patients were recruited. Besides CCL, all predictors were associated with non-organ-confined disease (p<0.001). Final pathology showed that 79 (56.4%) and 61(43.3%) had respectively a pT2 and a pT3 or greater disease. Rate of non-organ-confined disease increased from 44% in those individuals with only 1 predictor (OR 7.71, 95% CI 1.63-13.60), to 92.3% in those where 4 predictors were simultaneously observed (OR 72.00, 95% CI 8.31-623.44). At MLRM, the most significant risk factors for EPE were visible ECE (OR 9.66; 95%CI 3.64–25.66; p<0.0001), positive digital rectal examination (OR 3.43; 95%CI 1.33–8.89; p=0.011) and capsular bulge (OR 3.28, 95%CI 1.26–8.54, p=0.015). Presence of ECE at microUS predicted EPE with a sensitivity of 72.1% and a specificity of 88%, a negative predictive value of 80.5% and positive predictive value of 83.0%. CONCLUSIONS: Our findings suggest that microUS may represent an accurate tool for the evaluation of non-organ confined PCa. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e177-e177 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vittorio Fasulo More articles by this author Rozzano More articles by this author Federica Regis More articles by this author Marco Paciotti More articles by this author Francesco Persico More articles by this author Davide Maffei More articles by this author Alessandro Uleri More articles by this author Alberto Saita More articles by this author Rodolfo Hurle More articles by this author Massimo Lazzeri More articles by this author Paolo Casale More articles by this author Giorgio Guazzoni More articles by this author Nicolò Buffi More articles by this author Giovanni Lughezzani More articles by this author Expand All Advertisement Loading ...