Prebiopsy Prostate-specific Antigen Research Articles

Consistent predictive ability of prostate-specific antigen density prediction model for clinically significant prostate cancer across age strata.

Prebiopsy prostate-specific antigen density (PSAD) is a well-known predictor of clinically significant prostate cancer (csPCa). Since prostate-specific antigen(PSA) and prostate volume (PV) increase normally with aging, PSAD thresholds may vary. The purpose of the study was to determine if PSAD was predictive of csPCa in different age strata. We retrospectively reviewed our institutional database for patients who underwent multiparametricmagnetic resonance imaging (MRI) between January 2016 and December 2021. We included patients who had post-MRI prostate biopsies. Based on age, we divided our cohort into four subgroups (groups 1-4): <55, 55-64, 65-74, and ≥75 years old. PSAD accuracy was estimated by the area under the curve (AUC) as a predictive model for differentiating csPCa between the groups. CsPCa was defined as a Gleason Grade Group 2 or higher. Three different PSAD thresholds (0.1, 0.15, and 0.2) were tested across the groups for sensitivity, specificity, and positive predictive value (PPV) and negative predictive value(NPV). Chi-square and analysis of variance tests were used for bivariate analysis. All analyswere completed using R 4.3 (R Core Team, 2023). Among 1913 patients, 883 (46.1%) had prostate biopsies. In groups 1, 2, 3, and 4, there were 62 (7%), 321 (36.4%), 404 (45.8%), and 96 (10.9%) patients, respectively. Median PSA was 5.6 (interquartile range 3.4-8.1), 6.2 (4.8-9), 6.8 (5.1-9.7), and 9 (5.6-13), respectively (p < 0.01). Median PV was 42.3 (30-62), 51 (36-77), 55.5 (38-85.9), and 59.3 (42-110) mL, respectively (p < 0.01). No difference was observed in median PSAD between age groups 1-4 (0.1 [0.07-0.16], 0.11 [0.08-0.18], 0.1 [0.07-0.19], and 0.1 [0.07-0.2]), respectively (p = 0.393). CsPCa was diagnosed in 241 (27.3%) patients, of which 10 (16.1%), 65 (20.2%), 121 (30%), and 45 (46.7%) were in groups 1-4, respectively (p < 0.001). For groups 1-4, the PSAD AUC for predicting csPCa was 0.75, 0.68, 0.71, and 0.74. While testing PSAD threshold of 0.15 across the different age groups (1-4), the PPV vs.NPV was 39.1 vs. 93.2, 33.6 vs. 87, 50.9 vs. 80.8, and 66.1 vs. 64.7, respectively. PSAD prediction model was found to be similar among different age groups. In young patients, PSAD had a high NPV but low PPV. With increasing age, the opposite trend was observed, likely due to higher disease prevalence. While PSAD thresholds may be less useful in older patients to rule out higher-grade prostate cancer, the clinical consequences of these diagnoses require a case-by-case evaluation.

The treatment landscape of nonmetastatic castrate resistant prostate cancer: A contemporary perspective

ObjectivesThe incidence of nonmetastatic castrate resistant prostate cancer (nmCRPC) is not well defined in contemporary practice. The aim of this study is to describe the incidence and patterns of treatment of nmCRPC over the last 6 years at a single high-volume Australian health institution. Subjects and methodsAll men newly diagnosed with prostate cancer at Western Health, Melbourne from January 2016 to December 2021 were included in the study. Those diagnosed with nonmetastatic prostate cancer and treated with medical or surgical castration for biochemical failure post attempted curative therapy were retrospectively reviewed for signs of castration resistance using prostate specific antigen (PSA) and testosterone biochemical markers up until October 2022. ResultsFrom January 2016 to December 2021, 822 patients were diagnosed with prostate cancer, 590 had localized disease, 373 underwent definitive locoregional therapy, and 31 went on to have biochemical recurrence and were commenced on androgen deprivation therapy. Twenty-five patients had undetectable PSA levels and were classified as having nonmetastatic castrate sensitive prostate cancer (nmCSPC), whilst the remaining 6 patients experienced a rising PSA and were thus classified as nmCRPC. The incidence rate of nmCRPC was 228 cases per 100,000 person-years.The median age at the time of prostate biopsy was 74 years (interquartile range [IQR] 64–79) in the nmCRPC group and 62 years (IQR 57–69) in the nmCSPC group. The median prebiopsy PSA (ng/ml) in the nmCRPC and nmCSPC groups were 27.5 (IQR 19.9–50.4), and 16.5 (IQR 9.0–26.0), respectively. The median duration from prostate cancer diagnosis to onset of nmCRPC was 24 months (IQR 17–29) and the median PSA doubling time was 3.4 months (IQR 2.2–5.7). ConclusionsThus, nmCRPC is an uncommon disease. Further population-based studies are required to better understand the incidence of nmCRPC.

Association between prediagnostic prostate-specific antigen and prostate cancer probability in Black and non-Hispanic White men.

Although Black men are more likely than non-Hispanic White men to develop and die from prostate cancer, limited data exist to guide prostate-specific antigen (PSA) screening protocols in Black men. This study investigated whether the risk for prostate cancer was higher than expected among self-identified Black than White veterans based on prebiopsy PSA level. Multivariable logistic regression models were estimated to predict the likelihood of prostate cancer diagnosis on first biopsy for 75,295 Black and 207,658 White male veterans. Self-identified race, age at first PSA test, prebiopsy PSA, age at first biopsy, smoking status, statin use, and socioeconomic factors were used as predictors. The adjusted predicted probabilities of cancer detection on first prostate biopsy from the logistic models at different PSA levels were calculated. After controlling for PSA and other covariates, Black veterans were 50% more likely to receive a prostate cancer diagnosis on their first prostate biopsy than White veterans (odds ratio [OR], 1.50; 95% CI, 1.47-1.53; p<.001). At a PSA level of 4.0ng/mL, the probability of prostate cancer for a Black man was 49% compared with 39% for a White man. This model indicated that Black veterans with a PSA of 4.0ng/mL have an equivalent risk of prostate cancer as White veterans with a PSA of 13.4ng/mL. The findings indicate that, at any given PSA level, Black men are more likely to harbor prostate cancer than White men. Prospective studies are needed to better evaluate risks and benefits of PSA screening in Black men and other high-risk populations.

Outcomes of Cytoreductive Radical Prostatectomy for Oligometastatic Prostate Cancer on Prostate-specific Membrane Antigen Positron Emission Tomography: Results of a Multicenter European Study

BackgroundDe novo oligometastatic prostate cancer (omPCa) on prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is a new disease entity and its optimal management remains unknown. ObjectiveTo analyze the outcomes of patients treated with cytoreductive radical prostatectomy (cRP) for omPCa on PSMA-PET. Design, setting, and participantsOverall, 116 patients treated with cRP at 13 European centers were identified. Oligometastatic PCa was defined as miM1a and/or miM1b with five or fewer osseous metastases and/or miM1c with three or fewer lung lesions on PSMA-PET. InterventionCytoreductive radical prostatectomy. Outcome measurements and statistical analysisThirty-day complications according to Clavien-Dindo, continence rates, time to castration-resistant PCa (CRPC), and overall survival (OS) were analyzed. Results and limitationsOverall, 95 (82%) patients had miM1b, 18 (16%) miM1a, and three (2.6%) miM1c omPCa. The median prebiopsy prostate-specific antigen was 14 ng/ml, and 102 (88%) men had biopsy grade group ≥3 PCa. The median number of metastases on PSMA-PET was 2; 38 (33%), 29 (25%), and 49 (42%) patients had one, two, and three or more distant positive lesions. A total of 70 (60%) men received neoadjuvant systemic therapy, and 37 (32%) underwent metastasis-directed therapy. Any and Clavien-Dindo grade ≥3 complications occurred in 36 (31%) and six (5%) patients, respectively. At a median follow-up of 27 mo, 19 (16%) patients developed CRPC and eight (7%) patients died. The 1-yr urinary continence rate was 82%. The 2-yr CRPC-free survival and OS were 85.8% (95% confidence interval [CI] 78.5–93.7%) and 98.9% (95% CI 96.8–100%), respectively. The limitations include retrospective design and short-term follow-up. ConclusionsCytoreductive radical prostatectomy is a safe and feasible treatment option in patients with de novo omPCa on PSMA-PET. Despite overall favorable oncologic outcomes, some of these patients have a non-negligible risk of early progression and thus should be considered for multimodal therapy. Patient summaryWe found that patients treated at expert centers with surgery for prostate cancer, with a limited number of metastases detected using novel molecular imaging, have favorable short-term survival, functional results, and acceptable rates of complications.

Serum prostate-specific antigen trends and prostate cancer detection on follow-up in men with a prior negative biopsy: A cohort study

ABSTRACT Introduction: Elevated serum prostate-specific antigen (PSA) is the most common trigger for a prostate biopsy. However, the range of normal PSA is poorly defined in many populations. Men with “elevated” PSA may not harbor cancer, and it is unclear if such men with a prior negative prostate biopsy should be biopsied again. We conducted a cohort study to assess the PSA trends and cancer detection rates in such men. Methods: In an Institutional Review Board-approved ambispective study, men who underwent prostate biopsy between January 2016 and December 2021 for PSA &gt; 4 ng/mL were identified. Among them, those whose biopsy was negative for malignancy were contacted either telephonically or reviewed in person, and the most recent PSA and histopathology of any repeat prostate biopsy were determined. These were evaluated to assess the PSA trend, re-biopsy rate, and cancer detection rate. Results: During the study period, prostate biopsies were performed in a total of 1260 men; out of which 444 were negative for malignancy and 241 patients fulfilled the inclusion criteria. Their median prebiopsy PSA was 9.81 ng/mL (interquartile range [IQR]: 7.14–15.6), and the median follow-up PSA was 5.08 (IQR: 3.18–8.4). At a median follow-up of 53 months (range: 6–77 months), PSA had decreased in 177 (73.4%) patients, was static in 48 (19.9%) patients, and increased in only 16 (6.6%) patients. Repeat biopsy was performed on 20 patients; of whom seven had cancer (35%) with an overall positivity rate of 2.9% among the 241 patients. Although the positivity rate was higher in men with increased PSA, it was not statistically different from those with lower or similar PSA. No factors could be identified to predict a positive repeat biopsy. Conclusions: PSA, the sole trigger for a prostate biopsy, declined in nearly three-quarters of men with a negative first biopsy, and &lt;3% of men were detected to have cancer on a repeat biopsy. This information could help appropriately counsel patients and allay anxiety after a negative biopsy.

MP12-13 DISPARITIES IN PROSTATE MULTI-PARAMETRIC MAGNETIC RESONANCE IMAGING UTILIZATION IN BIOPSY NAIVE MEN

You have accessJournal of UrologyCME1 Apr 2023MP12-13 DISPARITIES IN PROSTATE MULTI-PARAMETRIC MAGNETIC RESONANCE IMAGING UTILIZATION IN BIOPSY NAIVE MEN Aroh Pandit, Tamir Sholklapper, Johnathan Drevik, and Serge Ginzburg Aroh PanditAroh Pandit More articles by this author , Tamir SholklapperTamir Sholklapper More articles by this author , Johnathan DrevikJohnathan Drevik More articles by this author , and Serge GinzburgSerge Ginzburg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003227.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Multi-parametric magnetic resonance imaging (mpMRI) prior to prostate biopsy has been recommended by the American Urologic Society (AUA) since 2019. Studies have shown biopsy naive men in minority groups are less likely to undergo mpMRI. We aimed to evaluate national trends in mpMRI utilization in biopsy naive men. METHODS: The TriNetX US Collaborative Network database of 90,863,999 patients was retrospectively queried using current procedure terminology codes for prostate biopsy and prostate mpMRI with associated dates. One cohort contained men with prostate biopsy without prior mpMRI. A second cohort contained men with biopsy and mpMRI prior. Inclusion was restricted to biopsies performed in 2017 or later. Men were excluded if they had a documented biopsy prior to 2017, or if pre-biopsy prostate specific antigen (PSA) was greater than or equal to 20ng/dL to exclude metastatic disease at presentation. Data was stratified by race, ethnicity, and region. Uni-variable logistic regression modeling was performed to evaluate the likelihood of using mpMRI prior to biopsy, odds ratios (OR) with 95% confidence intervals (CI) not crossing 1 were considered statistically significant. RESULTS: 49,590 men met inclusion for analysis, of which 39% had a pre-biopsy mpMRI. Compared to White men, Black and American Indian or Alaska Native men had a 15% and 39% lower likelihood of using mpMRI, respectively. Compared to non Hispanic men, Hispanic or Latino men had a 45% lower likelihood of using mpMRI. Men in the South and West had a 10% and 48% lower likelihood of using mpMRI, respectively, compared to men in the Northeast. CONCLUSIONS: In this nationwide clinical study, men in minority groups were less likely to undergo pre prostate biopsy mpMRI compared to men in majority groups. Additionally, men in the South and West were less likely to undergo pre prostate biopsy compared to men in the Northeast. Limitations include the retrospective nature and lack of inter-institutional standardization of coding. Further research is warranted to study the causation of these disparities. Source of Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e138 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aroh Pandit More articles by this author Tamir Sholklapper More articles by this author Johnathan Drevik More articles by this author Serge Ginzburg More articles by this author Expand All Advertisement PDF downloadLoading ...

Significance of the Percentage of Gleason Pattern 4 at Prostate Biopsy in Predicting Adverse Pathology on Radical Prostatectomy: Application in Active Surveillance.

To determine the prognostic significance of the maximum allowable percentage of Gleason pattern 4 (GP4) at prostate biopsy compared with adverse pathology observed at radical prostatectomy (RP) to expand active surveillance eligibility among a cohort with intermediate risk of prostate cancer. A retrospective study of patients with grade group (GG) 1 or 2 prostate cancer on prostate biopsy with subsequent RP was performed at our institution. A Fisher exact test was used to understand the relationship among GP4 subgroups (0%, ≤5%, 6%-10%, and 11%-49%) assigned at biopsy and adverse pathologic findings at RP. Additional analyses comparing the GP4 ≤5% cohort's prebiopsy prostate-specific antigen (PSA) level and GP4 length with adverse pathology at RP were also performed. No statistically significant difference in adverse pathology at RP was observed between the active surveillance-eligible control (GP4 0%) and the GP4 ≤5% subgroup. In total, 68.9% of the GP4 ≤5% cohort showed favorable pathologic outcomes. A separate analysis of the GP4 ≤5% subgroup revealed that neither prebiopsy serum PSA levels nor GP4 length showed statistical correlation with adverse pathology at RP. Active surveillance may be a reasonable option for management of patients in the GP4 ≤5% group until long-term follow-up data become available.

Correlation between Pre Biopsy Serum Prostate Specific Antigen Level and Gleason Score in Patients Diagnosed with Prostate Adenocarcinoma: A Hospital Based Study

Prostate Specific Antigen (PSA) is a non-invasive biomarker in the management of prostate adenocarcinoma. Due to its low specificity, its diagnostic role is controversial in prostate adenocarcinoma. Gleason score is considered as most powerful predictor of prostate carcinoma. PSA in combination with Gleason grading system improves the detection of pathological stage of prostate adenocarcinoma. Objective: To determine the degree of correlation between pre biopsy serum PSA level and Gleason score in patients diagnosed with prostate adenocarcinoma. Methods: Retrospective cross sectional study was conducted in Chemical Pathology and Histopathology department, Sheikh Zayed Hospital, Rahim Yar Khan between July 1, 2021 and September 31, 2022. A total of 51 histopathologically confirmed cases of prostate adenocarcinoma with documented Pre biopsy PSA level and Gleason score were included in the study. Serum PSA level correlation is compared with Gleason score, Gleason Pattern and Gleason Grade. p-value ≤0.05 taken as significant. Results: Mean age for prostate carcinoma patients was 65.71±10.062 years. Mean pre biopsy serum PSA level in study subjects was 40.31±37.52ng/ml. Of the total 51 study subjects, 27 (52.94%) were having Gleason score 7 suggestive of moderately differentiated tumor. Among these, 15(55.6%) were having serum PSA level between 10.01-50.00ng/ml. Statistically significant good correlation of serum PSA with Gleason score, Gleason pattern and Grade was established with p value &lt;0.05. Conclusion: It was concluded that there is good degree of positive correlation between pre biopsy PSA level and Gleason score in patients with Prostate adenocarcinoma

Preoperative predictive model of early urinary continence recovery after laparoscopic radical prostatectomy.

To develop and validate a predictive model include magnetic resonance imaging (MRI) parameters preoperatively which can assess the risk of incontinence after laparoscopic radical prostatectomy (LRP) accurately. We retrospectively reviewed and included 170 patients with prostate cancer who underwent LRP between July 2015 and June 2018 in our institution. All 170 patients were randomly resampled and divided into training set (n = 124) and verification set (n = 46) according to the ratio of 7:3. The Nomogram prediction model of the risk of incontinence after LRP was established through the training set and verified by the verification set. Baseline patient characteristics were obtained, including age, body mass index, and prostate volume. Perioperative characteristics such as pre-biopsy prostate specific antigen, biopsy Gleason score, clinical staging, and NVB sparing status were also collected. MRI parameters preoperatively including membranous urethral length (MUL), prostate apex depth ratio (PADR), and intravesical prostatic protrusion length (IPPL) were obtained. The C index and visual inspection of calibration curve were used to evaluate the discrimination and calibration of the model. According to the urinary incontinence (UI) at 3months postoperatively, the patients were divided into 104 cases (61.2%) in the group with no incontinence and 66 patients (38.8%) in the group with incontinence. Multivariate logistic regression analysis of training set showed that cT3a (OR = 0.427, 95% CI 0.142-1.281, P = 0.1288), MUL (OR = 0.237, 95% CI 0.102-0.551, P < 0.01), PADR (OR = 0.276, 95% CI 0.116-0.655, P < 0.01), and IPPL (OR = 0.073, 95% CI 0.030-0.179, P < 0.01) were independent predictors of urinary incontinence at 3months postoperatively. The model showed good discrimination with an area under the receiver operating characteristic (ROC) curve of 0.880, with the sensitivity and specificity 0.800 and 0.816, respectively, and good calibration (Hosmer-Lemeshow test result of 5.57, P = 0.695). Decision curve analysis demonstrated that the model was clinically useful. This study developed and validated a preoperative model in the form of a nomogram to predict the risk of UI after LRP at 3months. MUL, PADR, and IPPL were significant independent predictive factors of the postoperative early urinary continence.

Prostate magnetic resonance imaging-targeted biopsy global grade correlates better than highest grade with prostatectomy grade.

Magnetic resonance imaging (MRI)-targeted prostate biopsy has become an increasingly common method of diagnosing prostate cancer. A previous study from our institution demonstrated that the biopsy global Grade Group (gGG, aggregate GG of all positive cores) and highest Grade Group (hGGin any core) both show substantial concordance with the Grade Group at radical prostatectomy (RPGG) while the discordance predominantly consists of upgrading in gGG and downgrading in hGG. We performed a larger cohort study focused on biopsy cases in which gGG and hGG differ, to determine their relative concordance with RPGG. We conducted a retrospective review of radical prostatectomy specimens with prior MRI-targeted biopsies from our institution between 2016 and 2020. Separate gGG and hGG were assigned to each MRI-targeted lesion. Targeted lesions with different gGG versus hGG were segregated from those with identical gGG and hGG. The concordance of biopsy GG with RPGG was evaluated using κ coefficient analysis. Of the 489 lesions with MRI-targeted biopsies, 82 (17%) differed in gGG versus hGG. The gGG of 46 (56%), 33 (40%), and 3 (4%) lesions were unchanged, upgraded, and downgraded at radical prostatectomy, respectively (κ= 0.302, weighted κ = 0.334). The hGG of 24 (29%), 9 (11%), and 49 (60%) lesions were unchanged, upgraded, and downgraded at radical prostatectomy, respectively (κ = 0.040, weighted κ = 0.198). When stratified by the biopsy GG, gGG showed the highest concordance in GG2 (61%) and GG3 (54%) lesions. The hGG resulted in substantial downgrading (60%) with less optimal concordance regardless of the biopsy GG. Neither the prebiopsy prostate specific antigen level nor the PI-RADS score was predictive of upgrading of gGG. When gGG and hGG differ, gGG method more accurately predicts the RPGG than hGG, particularly in GG2 and GG3 lesions which comprised the majority of targeted lesions.

Rate of clinically significant prostate cancer on repeated biopsy after a diagnosis of atypical small acinar proliferation

Introduction: Current guidelines recommend repeat biopsy within 3-6 months for the diagnosis of atypical small acinar proliferation (ASAP) on prostate biopsy. Objectives: We aimed to evaluate the rate of progression of ASAP to clinically significant prostate cancer on repeat biopsy specimens and determine prognostic factors associated with progression. Patients and Methods: In a retrospective study we reviewed data of patients who had a prostate biopsy in our institution from March 2014 to March 2018. Gleason grade group (GGG) was conducted for pathology reporting. Logistic regression analysis was conducted for statistical analysis. Results: A total of 981 patients were identified of which 117 (12%) of them had a diagnosis of ASAP on their index biopsy. Out of these 16 (14%) patients underwent re-biopsy. Baseline clinicopathologic factors included a median age of 61 years, median pre-biopsy prostate-specific antigen (PSA) of 6.75 ng/mL and a mode of 1 core with ASAP. Median time interval between index and repeat biopsy was 10.5 months. The results of repeat biopsies were distributed across GGG system as follows; 12(75%) benign, 2 (12.5%) GG1, 1 (6.25%) GG2, and 1 (6.25%). We found no association between age, pre-biopsy PSA, and number of cores with ASAP, and progression of ASAP to clinically significant prostate cancer. Conclusion: Our study showed that patients with a diagnosis of ASAP are more likely to have a benign pathology on repeat biopsy. This finding supports previous studies regarding rethinking current guidelines for utility of repeat biopsy in patients with the diagnosis of ASAP.

EDITORIAL COMMENT

In this study, Seiden and colleagues1 assessed the utility of genomic testing to risk stratify 63 Black men with prostate cancer eligible for active surveillance (AS) at King's County Hospital Center, which serves a predominantly under-represented minority population in Brooklyn. In 63% of the cohort, genomic testing was discordant with initial risk stratification, with 28 men being reclassified to a higher National Comprehensive Cancer Network (NCCN) risk category and this was independent of a pre-biopsy prostate specific antigen (PSA) >10 ng/ml, abnormal digital rectal examination (DRE) and a high Prostate Imaging-Reporting and Data System (PI-RADS) score.

Establishment of Prospective Registry of Active Surveillance for Prostate Cancer: The Korean Urological Oncology Society Database.

To establish a prospective registry for the active surveillance (AS) of prostate cancer (PC) using the Korean Urological Oncology Society (KUOS) database and to present interim analysis. The KUOS registry of AS for PC (KUOS-AS-PC) was organized in May 2019 and comprises multiple institutions nationwide. The eligibility criteria were as follows: patients with (1) pathologically proven PC; (2) pre-biopsy prostate-specific antigen (PSA) ≤20 ng/mL; (3) International Society of Urological Pathology (ISUP) grade 1 or 2 (no cribriform pattern 4); (4) clinical T stage ≤T2c; (5) positive core ratio ≤50%; and (6) maximal cancer involvement in the core ≤50%. Detailed longitudinal clinical information, including multi-parametric magnetic resonance imaging and disease-specific outcomes, was recorded. From May 2019 to June 2021, 296 patients were enrolled, and 284 were analyzed. The mean±standard deviation (SD) age at enrollment was 68.7±8.2 years. The median follow-up period was 11.2 months (5.9-16.8 mo). Majority of patients had pre-biopsy PSA ≤10 ng/mL (91.2%), PSA density <0.2 ng/mL² (79.7%), ISUP grade group 1 (94.4%), single positive core (65.7%), maximal cancer involvement in the core ≤20% (78.1%), and clinical T stage of T1c or lower (72.9%). Fifty-two (18.3%) discontinued AS for various reasons. Interventions included radical prostatectomy (80.8%), transurethral prostatectomy (5.8%), primary androgen deprivation therapy (5.8%), radiation (5.8%), and focal therapy (1.9%). The mean±SD time to intervention was 8.9±5.2 months. The reasons for discontinuation included pathologic reclassification (59.6%), patient preference (25.0%), and radiologic reclassification (9.6%). Two (4.8%) patients with pathologic Gleason score upgraded to ISUP grade group 4, no biochemical recurrence. The KUOS established a successful prospective database of PC patients undergoing AS in Korea, named the KUOS-AS-PC registry.

Development and Validation of an Artificial Intelligence–Powered Platform for Prostate Cancer Grading and Quantification

The Gleason grading system has been the most reliable tool for the prognosis of prostate cancer since its development. However, its clinical application remains limited by interobserver variability in grading and quantification, which has negative consequences for risk assessment and clinical management of prostate cancer. To examine the impact of an artificial intelligence (AI)-assisted approach to prostate cancer grading and quantification. This diagnostic study was conducted at the University of Wisconsin-Madison from August 2, 2017, to December 30, 2019. The study chronologically selected 589 men with biopsy-confirmed prostate cancer who received care in the University of Wisconsin Health System between January 1, 2005, and February 28, 2017. A total of 1000 biopsy slides (1 or 2 slides per patient) were selected and scanned to create digital whole-slide images, which were used to develop and validate a deep convolutional neural network-based AI-powered platform. The whole-slide images were divided into a training set (n = 838) and validation set (n = 162). Three experienced academic urological pathologists (W.H., K.A.I., and R.H., hereinafter referred to as pathologists 1, 2, and 3, respectively) were involved in the validation. Data were collected between December 29, 2018, and December 20, 2019, and analyzed from January 4, 2020, to March 1, 2021. Accuracy of prostate cancer detection by the AI-powered platform and comparison of prostate cancer grading and quantification performed by the 3 pathologists using manual vs AI-assisted methods. Among 589 men with biopsy slides, the mean (SD) age was 63.8 (8.2) years, the mean (SD) prebiopsy prostate-specific antigen level was 10.2 (16.2) ng/mL, and the mean (SD) total cancer volume was 15.4% (20.1%). The AI system was able to distinguish prostate cancer from benign prostatic epithelium and stroma with high accuracy at the patch-pixel level, with an area under the receiver operating characteristic curve of 0.92 (95% CI, 0.88-0.95). The AI system achieved almost perfect agreement with the training pathologist (pathologist 1) in detecting prostate cancer at the patch-pixel level (weighted κ = 0.97; asymptotic 95% CI, 0.96-0.98) and in grading prostate cancer at the slide level (weighted κ = 0.98; asymptotic 95% CI, 0.96-1.00). Use of the AI-assisted method was associated with significant improvements in the concordance of prostate cancer grading and quantification between the 3 pathologists (eg, pathologists 1 and 2: 90.1% agreement using AI-assisted method vs 84.0% agreement using manual method; P < .001) and significantly higher weighted κ values for all pathologists (eg, pathologists 2 and 3: weighted κ = 0.92 [asymptotic 95% CI, 0.90-0.94] for AI-assisted method vs 0.76 [asymptotic 95% CI, 0.71-0.80] for manual method; P < .001) compared with the manual method. In this diagnostic study, an AI-powered platform was able to detect, grade, and quantify prostate cancer with high accuracy and efficiency and was associated with significant reductions in interobserver variability. These results suggest that an AI-powered platform could potentially transform histopathological evaluation and improve risk stratification and clinical management of prostate cancer.

NCCN Risk Reclassification in Black Men with Low and Intermediate Risk Prostate Cancer After Genomic Testing

ObjectivesTo assess the utility of genomic testing in risk-stratifying Black patients with low and intermediate risk prostate cancer. MethodsWe retrospectively identified 63 Black men deemed eligible for active surveillance based on National Comprehensive Cancer Network (NCCN) guidelines, who underwent OncotypeDx Genomic Prostate Score testing between April 2016 and July 2020. Nonparametric statistical testing was used to compare relevant features between patients reclassified to a higher NCCN risk after genomic testing and those who were not reclassified. ResultsThe median age was 66 years and median pre-biopsy PSA was 7.3. Initial risk classifications were: very low risk: 7 (11.1%), low risk: 24(38.1%), favorable intermediate risk: 31(49.2%), and unfavorable intermediate risk: 1 (1.6%). Overall, NCCN risk classifications after Genomic Prostate Score testing were significantly higher than initial classifications (P=.003, Wilcoxon signed-rank). Among patients with discordant risk designations, 28(28/40, 70%) were reclassified to a higher NCCN risk after genomic testing. A pre-biopsy prostate specific antigen of greater than 10 did not have significantly higher odds of HBR (OR:2.16 [95% CI: 0.64,7.59, P=.2). Of favorable intermediate risk patients, 20(64.5%) were reclassified to a higher NCCN risk. Ultimately, 18 patients underwent definitive treatment. ConclusionsIncorporation of genomic testing in risk stratifying Black men with low and intermediate-risk prostate cancer resulted in overall higher NCCN risk classifications. Our findings suggest a role for increased utilization of genomic testing in refining risk-stratification within this patient population. These tests may better inform treatment decisions on an individualized basis.

Definition of Outcome-Based Prostate-Specific Antigen (PSA) Thresholds for Advanced Prostate Cancer Risk Prediction.

Simple SummaryIn this study, we used a well calibrated risk prediction model to define prostate-specific antigen (PSA) thresholds for identifying or excluding advanced prostate cancer (PCa) as an aid to personalize management of the diagnostic workup. PSA concentrations ≤ 4.1 (<65 years old) and ≤3.7 μg/L (≥65 years old) excluded an advanced PCa in patients without glandular inflammation, while PSA > 5.7 (<65) and >6.1 μg/L (≥65) suggested a biopsy referral. In the presence of glandular inflammation, PSA does not provide a valid estimate for risk of advanced cancer since the marker variability is higher and the pre-test probability of PCa is low in this group. The proposed PSA thresholds may allow an individualized approach to the diagnostic workup, assisting patients in making an informed decision. However, patients with asymptomatic prostatitis cannot benefit from the use of this model since they cannot be pre-biopsy identified.We defined prostate-specific antigen (PSA) thresholds from a well calibrated risk prediction model for identifying and excluding advanced prostate cancer (PCa). We retrieved 902 biopsied patients with a pre-biopsy PSA determination (Roche assay). A logistic regression model predictive for PCa including the main effects [i.e., PSA, age, histological evidence of glandular inflammation (GI)] was built after testing the accuracy by calibration plots and Hosmer-Lemeshow test for goodness of fit. PSA thresholds were derived by assuming a diagnostic sensitivity of 95% (rule-out) and 80% (rule-in) for overall and advanced/poorly differentiated PCa. In patients without GI, serum PSA concentrations ≤ 4.1 (<65 years old) and ≤3.7 μg/L (≥65 years old) excluded an advanced PCa (defined as Gleason score ≥ 7 at biopsy), with a negative predictive value of 95.1% [95% confidence interval (CI): 83.0–98.7] and 88.8% (CI: 80.2–93.9), respectively, while PSA > 5.7 (<65) and >6.1 μg/L (≥65) should address biopsy referral. In presence of GI, PSA did not provide a valid estimate for risk of advanced cancer because of its higher variability and the low pre-test probability of PCa. The proposed PSA thresholds may support biopsy decision except for patients with asymptomatic prostatitis who cannot be pre-biopsy identified.

Performance of transgluteal CT-guided biopsy of prostate lesions in men without rectal access: A retrospective study

ObjectiveTo retrospectively study the performance of CT-guided biopsy of target prostate lesions at a single institution. MethodsBetween May 2016 and February 2021, we retrospectively identified all men without rectal access who underwent transgluteal CT-guided biopsy of PIRADS 4 or 5 targets detected on multiparametric MRI (n = 9). Clinical, radiological, and pathological details were collected by review of the electronic medical record, and included age, pre-biopsy prostate specific antigen (PSA) value, prior biopsy history, biopsy targeting technique and procedural details, complications, and final histologic diagnosis. Two targeting techniques were used: Localizing with anatomic landmarks or localizing with contrast enhancement. ResultsMean patient age was 69 years (range, 49–74) and mean PSA was 14.6 ng/mL (range 7–23). Four lesions were targeted using anatomic landmarks and 5 were targeted using contrast enhancement. All biopsies were technically successful and all resulted as prostate cancer. Three biopsies showed Gleason 6 cancer and 6 biopsies showed clinically significant prostate cancers with Gleason 7 or above. There were no major complications. 7 patients went on to definitive treatment with surgery or radiation. ConclusionTransgluteal CT-guided biopsy of MRI detected prostate lesions diagnoses clinically significant prostate cancer without complication and therefore should be considered for patients without a rectum.

Is pre-biopsy serum prostate specific antigen retesting always justified? A study of the influence of individual and analytical factors on decision making for biopsy referral

Background and aimsWe investigated factors influencing pre-biopsy prostate-specific antigen (PSA) retesting as recommended by clinical guidelines. Materials and methods333 patients screened for prostate cancer (PCa) repeated PSA (Roche Cobas systems) after a median of 3.9 months, before performing biopsy. Multiple regression models were used to assess effects of patients’ characteristics on PSA results and changes over time. ResultsPCa [n = 132 (40.7%)] and cancer-free [n = 192 (59.3%)] patients had similar rate of PSA positive results at baseline (84.8% vs. 83.9%, P = 0.931). Their rate of reversion to normal PSA after retesting was negligible (0.9% in PCa and 3.7% in PCa-free patients, P = 0.286). 31.1% of PCa and 31.3% of cancer-free patients (P = 0.426) showed a significant PSA increase after retesting. Age was a confounder since not only PSA increased in older PCa patients, but it was also related to PCa histological grade, in turn associated to PSA increase. In PCa-free patients, glandular inflammation, present in 1/3 of subjects, was also associated to higher PSA concentrations. ConclusionWhen obtained with the same immunoassay under controlled analytical conditions, a PSA positive result is confirmed after retesting in the great majority of screened patients. Neither analytical factors nor intraindividual variability appeared to justify PSA retesting before biopsy referral.

The presence of prostate-specific antigen checked more than 1 year before diagnostic biopsy is an independent prognostic factor in patients undergoing radical prostatectomy.

PurposeIn large scale prospective studies, prostate-specific antigen (PSA)-screening not only decreased prostate cancer mortality, but also reduced biochemical recurrence (BCR) in patients undergoing radical prostatectomy (RP). We investigated the independent effect of the presence of PSA checked more than 1 year before diagnostic biopsy on the prognosis of patients undergoing RP in a real world setting without PSA-screening.Materials and MethodsWe reviewed the database of patients undergoing RP at Ajou University Hospital from March 1999 to May 2018. Clinicopathological features assessed were age, presence of lower urinary tract symptoms at presentation, presence of PSA checked over 1 year before biopsy, presence of PSA checked within 4 to 1 years of biopsy, last pre-biopsy PSA (pPSA), biopsy grade group (bGG), cT, cN, percentage of positive biopsy cores (PPBC), pathological GG (pGG), pT, pN, surgical margin, and index tumor diameter. The primary endpoint was BCR-free survival (BCRFS).ResultsOf 598 patients enrolled, 211 experienced BCR at the mean follow-up of 64±37 months. The 5-year and 10-year BCRFS were 62.8% and 53.9%, respectively. In multivariate analyses including clinical variables only, pPSA, bGG, cT, PPBC, and PSA within 4 to 1 years of biopsy independently affected BCRFS. In multivariate analyses including pathological variables only, pPSA, pGG, pT, pN, PSA checked over 1 year before biopsy and PSA checked within 4 to 1 years of biopsy independently affected BCRFS.ConclusionsPatients who has checked PSA at least once beyond 1 year before diagnosis of prostate cancer show better BCRFS regardless of other factors.

Extended 14-core schematic diagram mapping prostate biopsy increases both the cancer detection rate and the accuracy of Gleason Score

Objective: To evaluate the effectiveness of extended 14-core schematic diagram mapping prostate biopsy for improving the cancer detection rate (CDR) and accuracy of Gleason score. Material and Method: This study included 184 patients who underwent transrectal ultrasound (TRUS)-guided lateral sextant biopsy (group I) and 196 patients who underwent extended 14-core biopsy (group II). Inclusion criteria for prostate biopsy were elevated serum prostate-specific antigen (PSA) levels (&gt;4.0 ng/ml) and/or suspicious digital rectal examination (DRE). Results: Median patient age was 69.68 years (±7.89) and 70.07 years (±8.83) for group I and II, respectively. Median pre-biopsy PSA was 18.04 (range: 8.42-22.35) and 15.83 ng/ml (range: 6.54-21.72) for group I and II. Out of the first group, 65 (35.3%) patients had prostate cancer, whereas 78 (40.0%) patients of group II had cancers. The overall cancer detection rate was significantly higher in group II (40.0%) than group I (35.3%), p=0.034, and in particular showed a significant increase in the cancer detection rate in the subgroup with PSA level between 4-10 ng/ml. Moreover, rising Gleason sum after radical prostatectomy was 1 in 3 (11.1%) patients and 2 in 1 (3.7%) patient. Conclusion: Extended 14-core schematic diagram mapping prostate biopsy significantly increased the cancer detection rate of prostate cancer and increased the accuracy of biopsy Gleason score. Thus, schematic diagram mapping prostate biopsy should be the standard ultrasound guided prostate biopsy in our institute for increasing the cancer detection rate and also for planning treatments.